Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 30 (5) June 2020
www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

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

Contents

page
Wearing masks and face covers as social responsibility during
the COVID-19 pandemic - Statement of the World Emergency
COVID19 Pandemic Ethics (WeCope) Committee
197
Statement on ethical triage guidelines for COVID-19 World
Emergency COVID19 Pandemic Ethics (WeCope) Committee 198
Ethical guidelines for COVID-19 triage management
201-Nader Ghotbi, Marlon Patrick P. Lofredo, Maria do CéuPatrão Neves, Mireille D’Astous, Rhyddhi Chakraborty, Esra Bilir,
Thalia Arawi, Anke Weisheit, Hasan Erbay, Jasdev Singh Rai,
Anthony Mark Cutter, Mouna Ben Aziz & Darryl R.J. Macer
Healthcare professionals acting ethically under the risk ofstigmatization and violence during COVID-19 from media
reports in Turkey - Sukran Sevimli
207
Dabawenyos helping Dabawenyos in a spirit of Bayanihan:
CSOs and private persons’ works of compassion during COVID19 pandemic - Erikka June D. Forosuelo & Rogelio P. Bayod 213
Confidentiality of medical data and public safety and health221- Marlon Patrick P. Lofredo
Mobile contact tracing technology: way out or lock up?
226- Maria Patrão Neves
The application of artificial intelligence to the medical field:
report of a qualitative investigation
230-Taketoshi Okita, Atsushi Asai, Tsuyoshi Horie & Seiji Bito
The COVID-19 pandemic and social inequality234- Christopher Ryan Maboloc & Carmelle Ayra Ferrer
COVID-19 Age: Spirituality and Meaning Making in the Face ofTrauma, Grief and Deaths - Rogelio P. Bayod
238
Nursing in Pakistan: issues and challenges
242-Sumaira Khowaja-Punjwani
Empowering the poor and the front-liners; equality ofcapability in the time of COVID-19 pandemic
248-Gerry Arambala
Community quarantine in the Philippines254- Leandro S. Estadilla
Enhancing spiritual palliative care of Muslim patients: aperspective from Islamic theology
256-Mohammad Manzoor Malik
The ethical dilemma among healthcare professionals in the
midst of COVID-19 pandemic
260-Randy A. Tudy
Axel Honneth on social justice and the environment as a moralpractical concern
264-Victor John M. LoquiasThis includes many papers from the International Public HealthAmbassadors Conferences (Refer: www.eubios.info)

Editorial address, and all correspondence to:Prof. Darryl Macer
Email: darryl@eubios.info

Wearing masks and face covers as social
responsibility
duringthe
COVID-19
pandemic- Statement of the World Emergency COVID19 Pandemic
Ethics (WeCope) Committee (23 April 2020)
As experts in many fields, coming from many culturesand nations across the world, we declare that thescientific evidence is clear that there is an expectedadvantage to both individuals and those around them towear proper face covers including masks in publicduring the COVID-19 pandemic.
In the early stages of the COVID-19 epidemic andpandemic, a number of medical professionals, medical
authorities, governments and the World HealthOrganization (WHO) had denied there were advantages
for wearing masks, opposed wearing them, and/or
warned persons who wanted to wear masks that there
was a risk of using them due to what they saw as general
inappropriate use and/or providing a false feeling ofsafety. Unfortunately, in only a few countries mask use
was encouraged by the governments, despite longstanding evidence of their effectiveness (Jefferson et al.,
2001; Wu et al., 2004).
There appear to have been two common reasons for
opposing mask use. One is a genuine ignorance of theireffectiveness, and another is fear in many countries that
there were insufficient masks for medical staff. Whatever
the reasons, the communication was often flawed,
contradictory, unscientific, and/or deceptive, likely
causing harm through increased numbers who were
infected. This also has resulted in loss of public trust in
health leadership and management in some places, at atime when trust is critical.
Although by April 2020 most authorities havechanged their advice to actively recommend or evencompel citizens to wear face coverings and masks whenin public, the questions over failed public moral
responsibility and the accountability for this erroneous
advice should be looked at as a lesson of the COVID-19
pandemic. While some authorities order all persons towear masks in public because of the social advantages, incase where there are limited supplies, or affordability,
other face coverings may still protect against
transmission. Also, we do not agree with fines or
penalties against persons who do not wear masks in198

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

public spaces, but encourage honest communication andeducation.
The Precautionary Principle is widely recognized ininternational law, yet it was generally not applied wellduring the COVID-19 crisis. Many people thought thatthey should wear masks and we applaud their informed
choice, as well as the advices of some governments towear masks, and efforts to distribute masks to the public.
Article 4 of the Universal Declaration on Bioethics andHuman Rights states that human beings have bothautonomy and responsibility and that these should bebalanced. We also still urge all in positions of authority,
at least not to discourage mask use by concerned
persons, for any political, cultural, racial, economic orother reasons.
It has been quite a contrast in the policies announced
in different countries over whether people should wear
masks to protect themselves and others from infection
during the time of COVID-19 (Macer, 2020). This is avery simple example to illustrate the evolution ofindividual responsibility and group solidarity, although it
is related to rather diverse cultural traditions around theworld. We urge governments to be transparent in theirassessment of the epidemiological analysis and statistics,
and truthful in their public communication to uncover
the scale of damage caused by any erroneous advice tocitizens who wanted to wear masks, but did not wear
masks because of inappropriate guidance from thehealth authorities.
In a world where authorities ought to be
representatives of the people they serve, and a reference
for the informed choices that people make, truth,transparency and inclusion in partnership with civilsociety are essential, and the respect for social
responsibility is an ethical imperative.
References

Feng, Shuo et al., (2020) Rational use of face masks in the
COVID-19 pandemic, Lancet Respiratory Medicine Mar 20.
pii: S2213-2600(20)30134-X
Jefferson T, Del Mar CB, Dooley L, Ferroni E, Al-Ansary LA,
Bawazeer GA, van Driel ML, Nair NS, Jones MA, Thorning S,
Conly JM. (2001) Physical interventions to interrupt or
reducethespreadofrespiratory
viruses.
Cochrane Database of Systematic Reviews 2011, Issue 7. Art.
No.: CD006207. DOI: 10.1002/14651858.CD006207.pub4.
Macer, D.R.J. (2020) Wearing Masks in COVID-19 Pandemic, thePrecautionary Principle, and the Relationships between
Individual Responsibility and Group Solidarity. Eubios
Journal of Asian and International Bioethics 30(4) (May2020), 129-132.
Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ.
Presymptomatic Transmission of SARS-CoV-2 — Singapore,
January 23–March 16, 2020. MMWR Morb Mortal Wkly Rep
2020; 69:411–415.
Wu, Jiang, et al. (2004). “Risk Factors for SARS among Persons
without Known Contact with SARS Patients, Beijing, China”,
Emerg Infect Dis. 2004 Feb; 10(2): 210–216.
Members, World Emergency COVID19 Pandemic Ethics(WeCope) Committee:
Dr. Thalia Arawi (Lebanon)
Dr. Lian Bighorse (San Carlos Apache Nation, USA)
Dr. Rhyddhi Chakraborty (India, UK)
Mr. Anthony Mark Cutter (U.K.)
Dr. Mireille D'Astous (Canada)
Dr. Ayoub Abu Dayyeh (Jordan)

Dr. Nilza Maria Diniz (Brazil)
Dr. Hasan Erbay (Turkey)
Prof. Nader Ghotbi (Japan)
Prof. Soraj Hongladarom (Thailand)Prof. Dena Hsin-Chen Hsin (Taiwan)
Dr. Anower Hussain (Bangladesh)
Prof. Bang-Ook Jun (Republic of Korea)
Prof. Hassan Kaya (South Africa)
Dr. Sumaira Khowaja-Punjwani (Pakistan)
Prof. Julian Kinderlerer (South Africa)
Dr. Lana Al-Shareeda Le Blanc (Iraq)
Prof. Marlon Lofredo (the Philippines)
Prof. Darryl Macer (New Zealand) [Meeting Chair]
Dr. Endreya Marie McCabe (Delaware Nation, USA)
Prof. Erick Valdés Meza (Chile, USA)
Dr. Ravichandran Moorthy (Malaysia)
Prof. Firuza Nasyrova (Tajikistan)
Prof. Maria do Céu Patrão Neves (Portugal)
Prof. Deborah Kala Perkins (USA)Dr. Osama Rajkhan (Saudi Arabia)
Ms. Carmela Roybal (Tewa Nation, USA)
Prof. Mariodoss Selvanayagam (India)
Prof. Mihaela Serbulea (Romania)
Dr. Jasdev Rai Singh (England)
Dr. Raquel R. Smith (USA)Prof. Takao Takahashi (Japan)
Dr. Ananya Tritipthumrongchok (Thailand)
Dr. Anke Weisheit (Uganda)
Prof. Yanguang Wang (China)
https://www.eubios.info/world_emergency_covid19_pandemic_ethics_
committee

Inquiries to: Prof. Darryl Macer Email: darryl@eubios.info
Tel. +1-949-439-9307

Statement on ethical triage guidelines for
COVID-19- Statement of the World Emergency COVID19 Pandemic
Ethics (WeCope) Committee (31 May 2020)
Rationale
This is our statement, as experts from many fields,
cultures and nations across the world, having realizedthat tens of thousands of people have died in grimsituations of the COVID-19 pandemic not only from thelethal susceptibility that some people have to this novel
virus, but also because of insufficient infrastructure,human resources, protective equipment, and/or a lack ofclear triage decision making protocols. The severe
shortage of resources in response to the overwhelming
number of patients needing life-saving treatment has
reduced the ability of most healthcare systems toorganize a reasonable and ethical method for triage.
There have been instances of denial of access of criticallyill persons to basic medical care from hospitals,
excluding patients above a certain age from receiving
life-saving treatments in overwhelmed Intensive Care
Units (ICU), and instances where the poor andunderprivileged were not given equal and fair access toquality healthcare.
In this context as an independent, multidisciplinary
and cross-cultural committee, we urge all to reflect again
on the moral foundations of the widely accepted
principle of triage, and the reality of healthcare systems
unable to cope with the pandemic. We here provide
simple, practical, and defensible ethical guidelines fortriage management of COVID-19 patients based on theprinciples of love of life, respect for human dignity,Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
distributive justice, fairness, non-discrimination, shareddecision making, and beneficence. The ethical challenges
of COVID-19 include observance of the duties to care,promotion of moral equity, planning for uncertainty,
support for healthcare workers, protection of vulnerable
groups, and provision of practical and ethical policy
guidelines. Under no circumstances should the existenceof the triage protocol justify negligent public healthstrategies.
Recommendation 1: People need to know the ethicalbasis and moral justification when they, or their loved
ones, are denied treatment or access to scarce resources
such as ventilators or denied admission to a hospital.
Ethical foundations of triage
Triage is the sorting and allocation of treatment topatients, according to a system of priorities designed tomaximize the number of survivors. It involves
articulation of a policy by medical administrators,
and/or an assignment by medical professionals ofdegrees of urgency to patients to decide the order oftreatment when there is a large number of them. There
are different ethical theories to guide the process of
triage in hospitals overwhelmed by COVID-19 patients inneed of life-saving treatment. Egalitarianism seeks totreat patients equally; utilitarianism aims to maximize
the greatest benefit to the greatest number, measured by
the remaining life years that a decision may save; andprioritarianism argues for treating the sickest first,
which is the usual practice at emergency rooms in the
majority of healthcare settings.
Particularities of triage for COVID-19
Generally, patients who may be saved throughimmediate medical attention are treated first; others
who can wait are given a lower priority, and those who
are unlikely to be saved may not receive treatment withscarce resources that are needed to save lives in the firstgroup. The provision of treatment, therefore, depends onavailable resources. The difficulty with emergency
medical ethics is that the time required for emergency
healthcare professionals to make decisions in case of any
ethical conflict is limited. Patients may thus be divided
into the three categories of emergency cases who require
immediate treatment, priority cases with priority in thequeue for rapid assessment and treatment, and nonurgent cases who can wait their turn in the queue forassessment and treatment. In COVID-19, the separationof emergency cases from others is based on the presenceof serious respiratory distress, severe dehydration or
shock, mental status changes, and chest pain. In light ofreports of people who were not admitted to hospital,
rapidly deteriorating when left unsupervised at home,ignoring the care of COVID-19 patients should be
carefully examined in the context of the duty of care.
Ethical objections to selection of patients
Selection of patients based on personal characteristics(age, gender, profession, ethnicity, nationality, number of
dependents, disability, and so on) violates two
fundamental ethical principles: the principle of humandignity which values every human being equally, and theprinciple of social justice which requires equal

199

opportunities for all. None of the risk factors forpredicting a grave outcome in COVID-19 has been
proved as definitive in terms of prognosis and thus
treatment should not be denied based on an underlying
condition. Using old age as an excuse to deny treatment
is discriminatory, unethical, and in contradiction withbasic social and cultural values. The use of a ‘simple cutoff’ policy on age constitutes direct discrimination
because comorbidities may put a younger person at a
disadvantage compared with an older but healthierpatient. There should neither be any race, gender orculture-based discrimination so that everyone is treatedfairly, as all human beings have inherent dignity.
Recommendation 2: Triage committees should beformed in hospitals in preparation for times of crisis, tohelp assist healthcare professionals decide which patientswould get scarce resources based on clinical data.
Triage committees in the context of ethics committees
The healthcare system should establish independent,
multi-disciplinary ethics committees, if they do notalready exist. Bioethics and triage committees should
wherever possible make the difficult decisions, not thebedside health professionals who will keep doing theirbest for each and every patient. The triage committee
should be a small but always available group of 3 highly
respected
professionals,
withtwo
healthcare
professionals, for example a physician and a nurse, plus
an ethicist. The availability of an ethics committee 24/7
helps in making unbiased decisions and reduces theburden of choice on the healthcare team, who at the timeof triage are tasked with saving as many lives as possible.
It has been accepted for years in triage that the mostimportant criterion is survivability, so that only patients
who are unlikely to live, even with medical intervention,
would be kept off scarce resources such as ventilators,
and the highest priority would be for patients who arelikely to recover with ventilator support. Ideally, thecommittee should examine each patient anonymously,
and factors like race, ethnicity, and status should not
influence their decision. If the committee gives a priority
for children who are in the early phases of a normal
lifespan compared to an older person in otherwise
identical circumstances, it should be a public policy
decision of the wider community, noting that it is a formof ageism. as discussed above. Fairness as well astransparency over triage rules are important so that the
public can trust the healthcare system in respect withrationing decisions.
Independence of review and resources
We recommend separating the clinicians providing carefrom those making triage decisions through a “triage
officer” who communicates the decision to the clinicians,patients and their family, regular review of decisions bya centralized monitoring committee to ensure that there
are no inappropriate inequities, and regular review of
the triage algorithm to update it based on new
information. Sufficient resources should be provided toenable such a system including shared decision making,especially now with the hindsight that we have aftermonths living with COVID-19.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

Recommendation 3: The protection of the vulnerable isa core ethical principle.
There should be an upfront commitment to core values
at the start of any triage statement. Under certain
circumstances, triage is needed to optimize the benefit of
the healthcare system to the citizens, when the numberof severely sick patients needing intensive care is morethan the capacity of the healthcare system to try andsave them all. Some frail patients may not be goodcandidates for aggressive live-saving treatments,
especially when the chance of success is dim. We
recommend trying to have an informed discussion withfrail patients and relatives of the patient before making
difficult decisions.
Palliative care
Triage should prioritize patients who are most likely tobenefit from intensive care, in order to maximize thenumber of lives that can be saved. Triage policies must
consider palliative care for patients whose triage
decision does not include life-sustaining care, as well as
those who are likely to die from COVID-19. Patients whoare in a medically futile situation must not be ignored,
and can be provided with palliative care to ensure they
are pain free. The available usual basic care considered
as non-extraordinary measures, such as food or fluids
should not be withheld, either. When patients areseverely affected by pre-existing conditions, end-of-lifecare ethics do not necessarily consider that treatment
should be initiated, when it may result in additionalsuffering, burden or distress for patients. If treatments
are expected to aggravate patient suffering, level of caredecisions may allow the choice of palliative care without
aggressive treatment. Openness and transparency ofcommunication facilitate the difficult discussions about
end-of-life decisions. Efforts need to be made to allow
family members to be present at the time around the endof life, as regrettably many persons have passed away
separated from family members.
Recommendation 4: Age, gender, race, ethnicity, existingdisabilities, morbidities and/or chronic backgroundconditions should not be used to exclude and/or deny theneeded treatment or care to COVID-19 patients.
Only certain situations may be ethically considered as apriority in triage. Such a consideration should be basedon clinical and objective factors, and comply with theprotocol approved by a hospital, regional, or national
ethics committee1, in consultation with the broader
community, as follows:2
1 In some countries there may be national laws that restrict the

choices suggested in these recommendations; however, these
are addressed to persons at all levels including policy makers,
administrators, practitioners, patients and family members. We
do not suggest persons break their national laws, but reflect
and consider legal and administrative reforms.
2 Deviations from the protocol should be accepted only whenapproved by an ethics committee, but we note that in someplaces across the globe, there may be critical human resource
constraints. We also note that including a representative of
patients’ rights groups in triage committees may be anadvantage.

a) A competent patient may make an autonomous
decision on level of care, such as choosing palliative careover intubation/ventilator use when the chance of
success is very low. Patients can also provide an advancedirective, or a ‘durable’ power of attorney as theirsurrogate, in case they succumb into a more serious
situation in later stages.
b) After a patient has been provided with mechanicalventilation, the ventilator may not be withdrawn unlessthe treatment is determined to be futile and it is needed
to try and save another patient who may benefit from it.
c) Do-not-resuscitate-orders are an ethically acceptable
practice for patients when medical doctors have goodreason to judge resuscitation would be futile.
d) When a number of patients are being considered forallocation of a rationed resource such as ventilators,
priority is with those who are more likely to benefit fromit. Estimation of likely healthy life-years saved may be
included in determination of the potential benefit. This is
the only situation where age may be considered, not todeny treatment, but to decide saving whom may
significantly increase the life-years saved. The differencein the predicted healthy life years saved should besignificant to justify such a consideration.
e) Healthcare workers engaged in the care of COVID-19
patients who get sick and need a rationed resource suchas ventilators, can be given priority over non-healthcare
workers, because saving them will be to the benefit ofmany other patients.
f) Prioritization in the form of affirmative action may beconsidered by the committee as discussed above under“Ethical Objections to Selection of Patients”.
g) Prioritization in the form of affirmative action may beconsidered for other emergency responders who become
sick while performing their duties to save the lives ofothers.
Members, World Emergency COVID19 Pandemic Ethics(WeCope) Committee:
Dr. Thalia Arawi (Lebanon)
Dr. Mouna Ben Azaiz (Tunisia)
Dr. Lian Bighorse (San Carlos Apache Nation, USA)
Dr. Rhyddhi Chakraborty (India, UK)
Mr. Anthony Mark Cutter (U.K.)
Dr. Mireille D'Astous (Canada)
Dr. Ayoub Abu Dayyeh (Jordan)
Dr. Nilza Maria Diniz (Brazil)
Dr. Hasan Erbay (Turkey)
Prof. Nader Ghotbi (Japan)
Prof. Abhik Gupta (India)
Prof. Soraj Hongladarom (Thailand)Prof. Miwako Hosoda (Japan)
Prof. Dena Hsin-Chen Hsin (Taiwan)
Dr. Anower Hussain (Bangladesh)
Prof. Bang-Ook Jun (Republic of Korea)
Prof. Hassan Kaya (South Africa)
Dr. Sumaira Khowaja-Punjwani (Pakistan)
Prof. Julian Kinderlerer (South Africa)
Dr. Lana Al-Shareeda Le Blanc (Iraq)
Prof. Marlon Lofredo (the Philippines)
Dr. Manuel Lozano Rodríguez (Spain)
Prof. Darryl Macer (New Zealand)Prof. Raffaele Mantegazza (Italy)
Dr. Aziza Menouni (Morocco)
Dr. Endreya Marie McCabe (Delaware Nation, USA)
Prof. Erick Valdés Meza (Chile, USA)
Dr. Ravichandran Moorthy (Malaysia)
Prof. Firuza Nasyrova (Tajikistan)
Dr. Suma Parahakaran (Malaysia)
Prof. Maria do Céu Patrão Neves (Portugal)Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

harm in the community, and under no circumstances
should the existence of the triage protocol justify
negligent public health strategies. We are all human, but
let us do the best we can to move forward, and learn
together.

Prof. Deborah Kala Perkins (USA)Prof. Osama Rajkhan (Saudi Arabia)
Ms. Carmela Roybal (Tewa Nation, USA)
Prof. Mariodoss Selvanayagam (India)
Prof. Mihaela Serbulea (Romania)
Dr. Jasdev Rai Singh (England)
Dr. Raquel R. Smith (USA)Prof. Takao Takahashi (Japan)
Dr. Ananya Tritipthumrongchok (Thailand)
Dr. Lakshmi Vyas (UK)Prof. Yanguang Wang (China)
Prof. John Weckert (Australia)
Dr. Anke Weisheit (Uganda)

https://www.eubios.info/world_emergency_covid19_pandemi
c_ethics_committee
Inquiries to: Prof. Darryl Macer Email: darryl@eubios.info Tel.
+1-949-439-9307
References are available in the background paper:
Nader Ghotbi, Marlon Patrick P. Lofredo, Maria do Céu Patrão
Neves, Mireille D’Astous, Rhyddhi Chakraborty, Esra Bilir, Thalia
Arawi, Anke Weisheit, Hasan Erbay, Jasdev Singh Rai, AnthonyMark Cutter, Mouna Ben Aziz, Darryl R.J. Macer, and otherMembers of the World Emergency COVID-19 Pandemic Ethics(WeCope) Committee. (2020). Ethical guidelines for COVID-19
triage management. Eubios Journal of Asian and International
Bioethics. 30(6) (June), 201-207.

Ethical guidelines
management

for

COVID-19

201

triage-Nader Ghotbi,
Ritsumeikan Asia Pacific University (APU) Beppu city, Oita,
Japan Email: nader@apu.ac.jp-Marlon Patrick P. Lofredo, the Philippines- Maria do Céu Patrão Neves, Portugal- Mireille D’Astous, Canada- Rhyddhi Chakraborty, UK- Esra Bilir, Turkey- Thalia Arawi, Lebanon- Anke Weisheit, Uganda- Hasan Erbay, Turkey- Jasdev Singh Rai, UK- Anthony Mark Cutter, UK- Mouna Ben Aziz, Tunisia- Darryl R.J. Macer, New ZealandContext
These are difficult times. All around the world, tens of
thousands of people, young or old, rich or poor, from allwalks of life have died in grim situations of the COVID-19
pandemic, especially in places suffering from insufficient
infrastructure, human resources, protective equipment,
and/or lack of clear triage decision making protocols.
There have been instances of dumping of bodies in rental
trucks next to elderly homes, of denial of access ofcritically ill persons to basic medical care from hospitals,
or giving up on treating the elderly (just because of theirage). In this context as an independent, multidisciplinary
and cross-cultural committee, we humbly share thisreview to urge all to reflect again on the ethicalfoundations of the widely accepted ethical principle oftriage in light of dozens of statements on this topic, andthe reality of healthcare systems unable to cope with the
pandemic. Observing the needed precautions to preventfrom the transmission of the virus, and aiming for thetreatment of the disease are the best ways to reduce

Ethical foundations of triage
Triage is the sorting and allocation of treatment topatients, especially battle and disaster victims, according
to a system of priorities designed to maximize thenumber of survivors. It involves articulation of a policyby medical administrators, and/or an assignment by
medical professionals of degrees of urgency to persons
with injuries or illnesses to decide the order of treatment
when there is a large number of patients or casualties.
Generally, the persons who are thought to be saved
through immediate medical attention will be treatedfirst, others who can wait will be given a lower priority,and those who are unlikely to be saved will not betreated if lives can be saved in the first group. One of themost important reasons for the difficulty withemergency medical ethics is that the time required for
emergency healthcare professionals to make decisions incase of any ethical conflict is limited (Erbay, 2014). The
provision of treatment depends on available resources.
As an ethical minimum, patients who are in a medicallyfutile situation must not be ignored, and can be provided
with palliative care to ensure they are pain free.
However, in extreme and/or resource poor situations
there may be a shortage of all medicines including pain
relieving medication.
People need to know the ethical basis and moral
justification when they, or their loved ones are denied
treatment or access to scarce resources such as
ventilators or denied admission to a hospital, and may
even be unable to receive minimal healthcare, which is abasic human right. 3 Different ethical theories areavailable to guide the process of triage in hospitals
overwhelmed by COVID-19 patients in need of lifesaving treatment. For example, egalitarianism seeks totreat patients equally; utilitarianism aims to maximize
the greatest benefit to the greatest number, measured by
the remaining life years that a decision may save; andprioritarianism argues for treating the sickest first(Romeo, 2020), which is the usual practice at emergency
rooms at least in the majority of healthcare settings.
Steinkamp and Gordijn (2003) compare four methods of
ethical case deliberation including clinical pragmatism,
the Nijmegen method of ethical case deliberation,
hermeneutic dialogue, and Socratic dialogue, but believethat no single method of ethical case deliberation is ideal
for all kinds of moral problems; each method has
strengths and weaknesses that must be examined inrelation to the moral problem. Therefore, they
recommend methodological plurality. Patrão Neves(2020) distinguishes
between ‘rationing’and‘rationalization’ in attempts to mitigate the scarcity of3 This paper will not discuss the right to healthcare, which theauthors believe should include a right to be admitted to a
hospital, because as we note in many countries in the world
people do not live close enough to access a hospital, even undernormal circumstances.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

resources and to guarantee an equally respectfultreatment for every patient.
Examples of triage principles for COVID-19
around the world
There have been reports of medical doctors excluding
patients above a certain age (above 60 in some reports,
above 80 years of age, in others) from receiving lifesaving treatments in overwhelmed Intensive Care Units(ICU) (Bloomberg, The Guardian, The Sun News, 2020).
Using age as the only factor to decide on triage seems
discriminatory, unethical, and in contradiction with basicsocial and cultural values. However, the severe shortageof resources in response to the overwhelming number ofpatients needing life-saving treatment may have reduced
the ability of the system to organize a more reasonable
and ethical method for triage. That is why, many
healthcare institutions resort to a scoring system andsome to a lottery.
Italy and Spain among other countries, offer universal
healthcare coverage to all citizens yet some healthcare
institutions, and/or communities reported that they
were left with no choice but to exercise, at times, triage
policies based on age. The COVID-19 crisis is also
happening in countries where the poor andunderprivileged don’t have an equal and fair access toquality healthcare as well as in refugee camps andunderserved areas which have their own ecology of
disease that leads to differential access to treatment
based on socio-economic factors. For example, urban
slums and refugee camps suffer from a lack of adequate
infrastructure to allow the practice of hygiene, social
distancing or even access to clean water and basic
healthcare. Pandemics like COVID-19 can have adisastrous effect under such circumstances and thetriage system may also favor the wealthy and powerful.
Rosenbaum (2020) describes the triage of patientsduring the COVID-19 pandemic, in Italy, and refers to theuse of old age as a factor to deny ventilator usage for two
reasons: “to dedicate its limited resources to those whoboth stand to benefit most and have the highest chanceof surviving”. The example used is saving a 65-year-old
patient instead of an 85-year-old patient because thesaved patient would live longer and also have a bigger
chance of being saved. The utilitarian approach to triage
in this case implies saving considerably younger patients
who have an apparent advantage in chance of survival.
The same paper suggests three principles for triage:
separating clinicians providing care from those making
triage decisions through a “triage officer” backed by anexpert team of nurses and respiratory therapists, who
communicate the decision to the clinicians, the patient
and the family; regular review of decisions by acentralized monitoring committee to ensure that there
are no inappropriate inequities; and regular review of
the triage algorithm to update it based on new
information(Rosenbaum, 2020).
In the UK, triage usually follows the so-called Smart
Incident Command System which grades casualties toPriority 1 (needs immediate treatment), Priority 2 (canwait for a short time before transport to definitive
medical attention), Priority 3 (can be delayed before
transport), and Priority 4 (most likely to die even withtreatment) (Jill et al. 2006). The NHS has listed thefollowing groups as vulnerable during COVID-19: cancer
patients undergoing active chemotherapy, radiotherapy
or immunotherapy, or with malignancies in blood orbone marrow (leukemia, lymphoma, or myeloma),patients under immunosuppressive therapy, and those
suffering from cystic fibrosis, severe asthma, COPD, rarediseases and inborn errors of metabolism, and pregnant
women
with
heart
disease(www.nhs.uk/conditions/coronavirus-COVID-19/). With
these groups of vulnerable patients, if demand outstrips
the supply of resources for intensive care, it isrecommended that ICU triage should not be based on age
or existing comorbidities, and should not be
discriminatory over the value or worth of individuals.
Rather, the decision should be fair, compassionate,consistent and solely based on clinically relevant factors
and ability of the patients to benefit (BMJ 2020).
France is considering a four-tiered scoring systemthat attempts to predict who has the best chance forsurvival, based on the severity of a patient's illness,
existence of comorbidities and other risk factors, and thepatient’s chance of returning to a decent level of health;
the scores are added up into a point system, which alsoprioritizes children, pregnant women, and first
responders such as firefighters and healthcare workers(Daley, 2020).
In the USA, the triage system for COVID-19 patients
relies on a more complex system, with two primaryprinciples of “saving the most lives and saving the mostlife years,” which means the number of additional yearsof life that a patient may live after treatment. Suchconsideration still is more to the benefit of younger
patients (Gutel, 2020). Triage in USA follows secondaryprinciples as well, such as prioritizing the treatment ofhealthcare workers engaged in the disaster response andconsideration of the “life cycle status,” which again
favors the survival of younger patients (Gutel, 2020).
Berlinger et al. (2020) from the Hasting Center havereferred to the ethical challenges of COVID-19 in the faceof duties to care, to promote moral equity, to plan for
uncertainty, to support workers and protect vulnerable
groups, and to provide policy guidelines; they have also
provided ethical guidelines for institutional ethics
services responding to COVID-19. According to Dr.
Arthur Caplan, a professor of medical ethics, there
should be no race, gender or culture-based
discrimination so that everyone is treated fairly and age
should not be the primary factor in triage becausecomorbidities and underlying conditions may put ayounger person at a disadvantage compared with anolder but healthier patient (Hamblin, 2020). New Yorkcity had a team of experts and professionals from among
medical doctors, ethicists, public health experts, andlawyers draft a guideline for ventilator allocation in
2015. The guideline recommended the formation of
triage committees in hospitals in preparation for times ofcrisis, to decide which patients would get ventilators
based on health data provided by physicians (Thompson,2020). These triage committees should take the difficult
decisions, not the bed side health professionals who willkeep doing their best for each and every patient. The
triage committee should be a small but always available
group of 3 (an odd number) highly respected
professionals, with either two physicians, or a physician

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
and a nurse, plus an ethicist. The most importantcriterion is survivability, so that only patients who areunlikely to live, even with medical intervention, would
be kept off ventilators, and the highest priority for using
a ventilator would be for patients who are likely torecover with ventilator support. The committee should
examine each patient anonymously, so personal factors
like age, race, and status would not influence theirdecision.
However, Brooks (2020) has reported a particularly
higher mortality among African Americans in USA that
may be due to social determinants of health as well as
common comorbidities which may have placed them atthe end of the triage list; this of course would beconsidered as discriminatory. Similar ethnic biases havealso been found in Europe (Godin, 2020). There is also
an argument against discriminatory attitudes toward thedisabled and the mentally challenged which raises a newflag of unfairness and social discrimination (Please referto the WeCope Committee report on COVID-19 andPersons Living with Disabilities).
Some commonalities from guidelines for triage
in COVID-19
In this paper we aim to provide simple, practical, anddefensible ethical guidelines for triage management of
COVID-19 patients based on the principles of distributive
justice, fairness, non-discrimination, and beneficence.
We have come to these principles through literature
review, and online interviews with professionals allaround the world including medical doctors andethicists, and use ethical arguments to provide answers
to help governments, policy makers, hospitals, medical
doctors and other healthcare workers with the harddecision of triage for COVID-19 patients in overwhelmedfacilities. These guidelines should be clear and practicalso that healthcare workers can use them without
confusion over difficult terminology or philosophicaldebates. As much as possible, guidelines and proceduresshould be established on the ground of a fair process
approach and procedural justice (Kinlaw, 2007).
Pandemics raise ethical dilemmas related to theconflict between the duty to care and the duty to treat(Klugman, 2020; Selgelid, 2009; Godkin, 2003). The duty
to treat is challenged by the scarcity of resources andhaving people at multiple points in the chain of access toservices that are under limitations of triage; thoseanswering the telephone calls, dispatching ambulances,admitting patients into a medical building, and deciding
what type of treatment may be offered after admission
into the medical facility. One procedure being used in
Phoenix Indian Medical Center, for example, has been to
set up a tent outside the facility for initial screening of all
persons to identify which persons can enter the facility,
and where should they go. Another procedure being
used in many countries is to telephone ahead before
even coming to a medical facility, to advise persons if
they even have a chance to enter a facility, or if they areadvised to stay at home. The duty to care, on the other
hand, has led many nations to call their healthcare
workers heroes because they are risking their lives
caring for COVID-19 patients amidst a lack of sufficientpersonal protective equipment (PPE) and othersafeguards (Hsin and Macer, 2004). The refusal to treat

203

could have a drastic effect on triage. The heroism ofhealthcare workers is the main source of support for
COVID-19 patients, especially when protective personalequipment (PPE) is scarce and full protection is notavailable.
To guide healthcare workers in their duties to careand treatment in a triage situation, the World HealthOrganization (WHO) released the Emergency Triage
Assessment and Treatment guidelines that divides
patients into three main categories: emergency cases who
require immediate emergency treatment, priority cases
who must be given priority in the queue for rapid
assessment and treatment, and non-urgent cases who canwait their turn in the queue for assessment andtreatment (WHO, 2005). In COVID-19, the separation of
non-urgent cases from others is based on the presence of
respiratory distress (severe breathlessness, respiratory
exhaustion, increased respiratory rate), oxygen
saturation less than 93%, severe dehydration or shock(SBP less than 90 and/or DBP less than 60 mmHG),
mental status changes (confusion, agitation, seizures,
drowsiness, GCS < 15), and chest pain (CDC, 2020).
However, a difficult question is what to do when too
many patients need a scare resource such as a ventilator.
Vincent and Taccone (2020) suggest limiting the use oflife-sustaining therapies for ICU and hospital patientswith poor predicted outcomes associated with old age,frailty, comorbidities, or profound disability, or a lack ofpersonnel, beds, or materials. Domenicoa et al. (2020)
recommend that “If no effective treatment is found quickly,
triage decisions will have to be taken concerning access to
hospitals and ICUs”. They suggest that the triage should
prioritize patients who are most likely to benefit from
intensive care, in order to maximize the number of lives
that can be saved. They also recommend that triage
policies must consider palliative care for patients whose
triage decision does not include life-sustaining care, as
well as those who are likely to die from COVID-19(Domenicoa et al., 2020). The available usual basic careconsidered as non-extraordinary measures, such as foodor fluids should not be withheld, either.
Patrão Neves (2020) considers that the selection ofpatients based on personal characteristics (age, gender,
profession, ethnicity, nationality, number of dependents,etc.) violates two fundamental ethical principles: theprinciple of human dignity which values every humanbeing equally, and the principle of social justice which
requires equal opportunities for all. Therefore, it isimportant to make a distinction between rationing andrationalization. Rationing may be ethically acceptable
when the criteria of selection are transparent and refer
to non-vital resources. Rationalizing refers to the most
reasonable (‘rational’) use of limited resources solely
under the criterion of making the most of it; the goal is
optimization of available resources, making them as
efficient as possible. Therefore, in life and death
decisions, such as providing respiratory support for
COVID-19 patients, rationalization may be the only
ethical approach because it does not value some persons
in detriment of others, but chooses the optimization of
scarce resources.
Truog et al. (2020) explain that some triage
guidelines require saving the most lives, which implies a
consideration of the patient’s short-term likelihood of204

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

surviving the acute medical attack. Rationing should be
conducted through a triage officer or committee (which
may include ethicists) by those who are not directly
engaged in the care of the patient, and is done in threesteps. First, exclusion criteria are applied, such aswhether an irreversible shock has occurred. Next, themortality risk is evaluated through Sequential Organ
Failure Assessment (SOFA) score, to see whether thepatient should be given priority for initiating ventilation.
Third, assessments should be repeated over time, so thatpatients who are not improving may be removed fromthe ventilator to make it available for another patient(Truog et al., 2020). The tricky question here is when
one can really argue that a patient is not improving, after
a day, 2-3 days, or a week? They recommend thatphysicians proactively engage in a discussion withpatients and their families before the patient’s condition
has started to deteriorate. Such discussions need to bemade in the best possible way and include therequirements of safety and social distancing. They
recommend that ventilators be allocated to thosepatients who are most likely to benefit from them,because after a patient has been provided withmechanical ventilation, withdrawing the ventilator
would be a difficult decision to make. However, if thetreatment is determined to be futile, it needs to be done
to try and save another patient who may benefit from it(Truog et al., 2020). Discussions on ‘do-not-resuscitateorders’ have been made in USA (Cha, 2020; Na, 2020).
In Quebec, patients can decide the level of care thatwill be provided. A formula is provided by INESSS(Institut national d'excellence en santé et services
sociaux, at http://www.inahta.org/ members/inesss/)
with the aim to respect a person’s wishes and to
determine the medically-appropriate care that will bedelivered. When patients are severely affected by preexisting conditions, end-of-life care ethics do notnecessarily consider that treatment should be initiated,
especially when it may result in additional suffering,burden or distress for patients. The planning od advancecare decisions is delicate and sensitive. Openness andtransparency of communication can facilitate thedifficult discussions about end-of-life decisions. If
treatments are expected to aggravate patient suffering,level of care allows the choice of palliative care without
aggressive treatment. The four levels of care are: prolong
life with all necessary care (Goal A), prolong life withsome limitations to care (Goal B), ensure comfort as apriority over prolonging life (Goal C), and ensure
comfort without prolonging life (Goal D). A competentpatient can make an autonomous decision over the levelsof care or provide an advance healthcare directive.
Levels of care can also be a result of shared decision of a
doctor and the representative of the patients.
Schuklenk (2020) has emphasized on thepreeminence of fairness as well as transparency overtriage rules in any country, state, city, or hospital so thatthe public can trust the healthcare system in respectwith rationing decisions. The British Medical Association(BMA) warns against direct and indirect discriminationin prioritization decisions, as when medical doctors
resort to quick decision-making for its associatedbenefits. For instance, this attitude can be indirectly
discriminatory against the elderly; the use of a ‘simple

cut-off’ policy for age is unlawful and constitutes directdiscrimination. For example, a “healthy 75-year-old
cannot lawfully be denied access to treatment on thebasis of age” (BMA, 2020, p. 6). The guideline publishedby Michalowski et al. (2020) of the University of Essex
also rejects the use of advanced age as a triage criterion
because it discriminates against the elderly. Melnychuk
and Kenny (2006) criticized the utilitarian approach by
Christian et al. (2006) for the fact they the values andprinciples used are not explicit. They recommend theformulation of policy based on three values: equity, trust(fair processes and fair treatments) and solidarity. In
Lebanon and in the Arab world, such discrimination is
also considered a breach of religious practices whichmight leave the decision maker with a troubled
conscience and soul (Arawi, 2020).
Doctors and healthcare workers may contract SARSCoV-2 and suffer from COVID-19; therefore, ethical triage
should also provide recommendations for the medical
community (Emanuel, 2020). In fact, many healthcare
workers have died, and some died directly because oflimited personal protective equipment. The Statement
on European Solidarity and the Protection of
Fundamental Rights in the COVID-19 Pandemic mentions
the “disproportionate burden of this pandemic in caring
for patients” on healthcare workers. This was also seen
in SARS (Hsin and Macer, 2004). The Ebola outbreak inWest Africa (2014-2016) has shown the risk of harm tohealthcare workers. Since the priority should be toincrease the capacity of healthcare systems to handle thecases to the benefit of all, the recommendation toprioritize healthcare workers is not linked to their age or
status. It is also imperative that healthcare workers often
seek out, assess, and absorb information that underlie
their treatment decisions and options.
Fever clinics in Wuhan, China used a flowchart fortreatment of COVID-19 disease which is an algorithm fordecision-making support (Zhang et al. 2020). The main
factor implying gravity of the patient’s condition was
dyspnea/hypoxia with SpO2 less than 93%, but also
elevated C-reactive protein (CRP) and bilateral large
ground-glass opacities in the chest CT-scan, which
require admission for oxygen therapy. Ayebare et al.
(2020) modified the above algorithm by not using achest CT-scan in the situation of low-income countries
because it did not appear to significantly change themanagement strategy. A growing number of hospitals
are considering the use of automated tools to overcome
the shortage of staff in the face of overwhelming patientloads, so that they can manage the COVID-19 pandemic(Hao, 2020). In many countries, healthcare workers facea difficult situation over the lack of protective devices
which further hinders the job of triage at the point ofadmission. Under such circumstances, artificial
intelligence (AI) could help with a better and quicker
scoring of patients based on the agreed upon clinical aswell as prioritization criteria. The use of WIFI alsoenables the sharing of information among the healthcare
personnel in charge of triage without putting them atrisk of contamination. Medical doctors in Korea havereported that artificial intelligence (AI) using deeplearning techniques outperformed medical doctors intriage of trauma patients (Kang et al. 2020). The use of AI
may help with an objective implementation of triage

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
criteria and have it done more quickly. However, as thereview by Wynants et al. (2020) has shown, the current
prognosis prediction models for COVID-19 are of poor
quality and cannot be recommended for use.
Nonetheless, there is a possibility to use telemedicine
technologies to help realize a pre-triage (Hollande,2020). An ethical consideration is to make sure that Al
data are protected in respect to confidentiality ofpatients’ information.
Considering the differences in protocols and opinions
regarding triage in the COVID-19 pandemic as shown
above, there is a dire need for a global ethical frameworkthat makes clear the values and principles that will guide
pandemic response planning. Such a framework canclarify the values and principles that may guide theplanning of the response to the pandemic. The
development of such a framework involves actual effort
in the preparation of policy and its application; ethicists
would have an obligation to provide a clear
understanding why certain values are privileged andothers are not.
Conclusions
This review of literature and the online interviews of
medical doctors, ethicists and other professionals has
demonstrated the difficulty and challenges faced by thehealthcare systems, medical doctors, nurses and other
healthcare workers in providing the needed treatment
and care to an increasing number of patients in the
COVID-19 pandemic. In many places around the world,
hospitals have been overwhelmed with subsequent
shortages of trained staff for emergency care (especiallyintubation), as well as the needed ventilators forrespiratory support, usually provided in ICU
departments. Under these circumstances, triage isneeded to optimize the benefit of the system to thecitizens. There should be an upfront commitment to acouple of core values at the start of any triage statement.
One of the core ethical values is that the protection of thevulnerable should be regarded as a core principle.
Many of the previously developed decision-making
systems and guidelines for triage may be applied in the
new context of the COVID-19 pandemic. Availability of an
ethics committee 24/7 could help in making unbiased
decisions and reduce the burden of choice on thehealthcare team. Such a committee may consider apriority for children who are in the early phases of anormal lifespan. Some elderly and frail patients may not
be good candidates for aggressive live-saving
treatments, especially when the chance of success is dim.
Trying to have an informed discussion with an elderly
patient or relatives of the patient may be helpful before
making the decision. It may even be a good idea forpeople to have a discussion with their elder parents
earlier, particularly as the consequences of the disease,even after recovery, are extremely debilitating,particularly for elderly people. The number of severely
sick patients needing intensive care may be more thanthe capacity of the healthcare system to try and savethem all. However, none of the risk factors for predicting
a grave outcome and thus deny treatment to somepatients has been proved as reliable in terms ofprognosis (Wynants et al, 2020).

205

Recommendations for ethical guidelines
1) People need to know the ethical basis and moral
justification when they, or their loved ones, are denied
treatment or access to scarce resources such as
ventilators or denied admission to a hospital.
2) Triage committees should be formed in hospitals in
preparation for times of crisis, to help assist healthcare
professionals decide which patients would get scarce
resources based on clinical data.
3) The protection of the vulnerable is a core ethicalprinciple.
4) Age, gender, race, ethnicity, existing disabilities,
morbidities and/or chronic background conditions
should not be used to exclude and/or deny the needed
treatment or care to COVID-19 patients.
Only certain situations may be ethically considered asa priority in triage. Such a consideration should be basedon clinical and objective factors, and comply with theprotocol approved by a hospital, regional, or national
ethics committee4, in consultation with the broader
community, as follows:5a) A competent patient may make an autonomous
decision on level of care, such as choosing palliative careover intubation/ventilator use when the chance of
success is very low. Patients can also provide an advancedirective, or a ‘durable’ power of attorney as theirsurrogate, in case they succumb into a more serious
situation in later stages.
b) After a patient has been provided with mechanicalventilation, the ventilator may not be withdrawn unlessthe treatment is determined to be futile and it is needed
to try and save another patient who may benefit from it.
c) Do-not-resuscitate-orders are an ethically acceptable
practice for patients when medical doctors have goodreason to judge resuscitation would be futile.
d) When a number of patients are being considered forallocation of a rationed resource such as ventilators,
priority is with those who are more likely to benefit fromit. Estimation of likely healthy life-years saved may be
included in determination of the potential benefit. This is
the only situation where age may be considered, not todeny treatment, but to decide saving whom may
significantly increase the life-years saved. The differencein the predicted healthy life years saved should besignificant to justify such a consideration.
e) Healthcare workers engaged in the care of COVID-19
patients who get sick and need a rationed resource suchas ventilators, can be given priority over non-healthcare
workers, because saving them will be to the benefit ofmany other patients.

4 In some countries there may be national laws that restrict the

choices suggested in these recommendations; however, these
are addressed to persons at all levels including policy makers,
administrators, practitioners, patients and family members. We
do not suggest persons break their national laws, but reflect
and consider legal and administrative reforms.
5 Deviations from the protocol should be accepted only whenapproved by an ethics committee, but we note that in someplaces across the globe, there may be critical human resource
constraints. We also note that including a representative of
patients’ rights groups in triage committees may be anadvantage.

206

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)f) Prioritization in the form of affirmative action may beconsidered by the committee as discussed above under“Ethical Objections to Selection of Patients”.
g) Prioritization in the form of affirmative action may beconsidered for other emergency responders who become
sick while performing their duties to save the lives ofothers.
Acknowledgements

We express our sincere thanks to other members of the World
Emergency COVID-19 Pandemic Ethics (WeCope) Committee
who provided feedback on this paper.

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Healthcare professionals acting ethicallyunder the risk of stigmatization andviolence during COVID-19 from media
reports in Turkey- Sukran Sevimli, M.D.
Department of Medical History and Medical Ethics, Dursun
Odabas Research Hospital, Faculty of Medicine, Van Yuzuncu
Yıl University, Turkey
Email: sukransevimli@gmail.com

Abstract
Aim: The COVID-19 infection is transmitted either byhuman-to-human contact, social-physical contact, andrespiratory droplets or by touching items touched by theinfected. This has triggered some conflicted behaviors
such as stigma, violence and opposite behavior applause.
The aim of this study is to explore several newspaper
articles about stigma, violence, or insensitive behavior
against healthcare professionals and to analyze reason ofthese behaviors during these COVID-19 pandemic.
Method: The website of the Turkish Medical Association"Press Releases News" and online newspaper articles
have been scanned using keywords and have beenclassified and analyzed according to the content ofarticles between the periods of March 11 to April 28,
2020. This is a qualitative study with content analysis.
No official ethical permission was obtained as the study
was conducted through open access internet news sites.
Result: 16 reports were selected from online reportsthat matched the keywords of the study. 13 of thesereports included desensitization, violence, lack of
precaution, stigmatization, and applause, and 3 reports
included doctors’ statements. After being categorized,
content analyses were conducted.
Conclusion: This study revealed the necessity of multifaceted evaluation of the problems faced by healthcare
professionals who are at the forefront of the COVID-19
outbreak. This study has a primary role in the detection,

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

diagnosis and treatment of the pandemic and reveals
that doctors are trying to fulfill their duties in an ethicalframework despite stigmatized behavior. Authorities
should provide various supports to protect healthcare
professionals before, during and after the epidemic forthe success of COVID-19 outbreak struggle.
Introduction
Pandemics are actually not new; the world has
experienced pandemics about every 10 or 50 years sincethe 16th century (WHO, 2005). However, the novel
coronavirus is affecting the world more now despiteadvanced medicinal advancements. Coronavirus, firstdescribed in the 1960s and found to be very common,has the ability to be passed from animal to human which
is why most people have encountered it at some point intheir life (WHO, 2007). The human coronavirus oftencauses mild to moderate upper respiratory diseases; it
can cause a variety of diseases, from the common cold tomore serious diseases such as the Middle East
Respiratory Syndrome (MERS-CoV) and Severe AcuteRespiratory Syndrome (SARS-CoV) (WHO, 2005).
Previous cases of pneumonia of unknown etiology in
Wuhan city of Hubei province, China were reported to
the World Health Organization (WHO) on December 31,
2019. It was then when WHO announced the discoveryof the novel coronavirus (2019-nCoV) and labeled it as
the sixth “international public health emergency” on
January 30, 2020 and later publicly announced apandemic on March 12, 2020 (WHO, 2020).
The COVID-19 infection is transmitted by human-tohuman contact, social-physical contact, and respiratory
droplets or by touching items touched by the infected. It
has been identified as having a median incubation timeof 4-5 days, yet the ability for transmission of the disease
may extend up to 14 days. These findings for COVID-19
and its infection methods are still the same; however,research may present new information that deepens theunderstanding of this virus.
Health stigmatization, humiliation, insensitivity andviolence: The basis of health stigma is perception of thesick person as an object that is contaminated andbecomes dangerous. This perception can lead to easily
giving up on helping people who are stigmatized without
any conscience and ethical concern.
Health stigma has been seen throughout history,
where people display negative and discriminatory
attitudes, stereotyping a person or group of people
experiencing a particular disease, where the disease
occurs, and things related to the infected diseases (e.g.,
HIV/AIDS, Ebola, SARS-CoV, MERS etc.) (WHO, 2007).
Unfortunately, the extent of labeling patients has
expanded during the COVID-19 pandemic, because
COVID-19 has infected people in very fast and easy ways,
and transmission can occur in a variety of forms,
including through air, social distance under 2m andexposed clothing. It has led to high morbidity andmortality around the world, and has seriously affectedinterpersonal relationships. For this reason, the high riskof contamination has increased stigmatization towards
patients (both confirmed and under investigation),including healthcare professionals (HCPs) who treat
COVID-19 patients. People’s approach to stigmatizing

infectious diseases has become more intense in the
COVID-19 period, to the extent of stigmatization
healthcare workers.
Pandemics and ethics in Turkey: The Hippocratic oath,medical deontology regulations (Türk Bakanlar Kurulu:
Turkish Council of Ministers, January 13, 1960), medical
ethics practices, and patients’ rights regulation (Turkish
Republic Ministry of Health, 1998) describe thephysician-patient relationship and require physicians toplace the patients’ welfare as their primaryconsideration in Turkey. Within the framework of theseregulations, as a general principle, healthcare
professionals are responsible for carrying out healthservices completely under any risk, including natural
disasters or pandemics.
As a matter of fact, the Ministry of Health canceled
the holiday permits of health professionals across thecountry immediately after the first COVID-19 cases
started to appear (excluding marriage, death, maternity
leave and accompanying leave under article 105, andunpaid leave under article 108, and under exclusion
article 104 of law No. 657) (Memurlar.net, 13 March
2020). Moreover, all health institutions across thecountry have started to work to solve medical, social andlegal problems that arise with the COVID-19 outbreak in
a short time. Therefore, the Ministry of Health prepared
new information and consent forms to prevent fromissues between patient/patient relatives and doctors on
March 13, 2020, e.g. COVID-19 patient/contact follow-up(quarantine) information and consent form, inpatient
information and consent form, consent form for patientsoutside COVID-19 diagnosis, COVID-19 patient
relatives/companion information and consent form, and
COVID-19 highly suspicious patient information andconsent form.
In the meantime, the Ministry of Health, the Turkish
Medical Association, and television networks started to
inform the public with various videos and discussion
programs about the COVID-19. However, the pandemic
in question was not taken seriously enough; somepatients tried to escape from the hospital, some left thequarantine, and COVID-19 suspects expected toquarantine themselves at home went to Mosque,
shopping or even funeral ceremonies. Moreover, these
preparations were not sufficiently considered by somesegments of the society, unfortunately, andstigmatization and attacks on health professionals
continued.
Research questions
This present study aims to explore the following
questions: Does COVID-19 reveal stigma and violence?
Does the attitude of some authorities or celebrities play
an important role in stimulating and normalizing
stigmatization and violence? The answers to thesequestions will contribute to an understanding of theshortcomings and inaccuracies regarding health stigma.
Findings and discussion
The present study’s data is based on reports collectedfrom online media. These reports demonstrated the
public knowledge of COVID-19 and the three main
attitudes seen as psychological support for HCPs;

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
however, stigma and violence against front line HCPs
was still present. Therefore, this study has included
comments of HCPs to better analyze the study situation,
as they play the most crucial and even the primary rolein this pandemic and want to fulfill these roles in the best
possible way.
There is an interesting perception of HCPs present
during the care of a patient as if they belong to anotherplace or class; that HCPs should treat their patients inthe best possible way, but they should also be blamed forproblems in the healthcare process. There is an
incomprehensible attitude as if HCPs are not human.
They are human; HCPs also have human rights and the
Universal Declaration on Bioethics and Human Rights,
UNESCO article 11 provides that “No individual or groupshould be discriminated against or stigmatized on any
grounds in violation of human dignity, human rights, andfundamental freedoms (UNESCO, 2005).

I.

Applause on one side, violence, blame,
stigmatization on the other
I.Applause: The morale of an applause campaign for
healthcare workers fighting coronavirus started inEurope and was then followed with therecommendations of National Assembly Health Minister
Fahrettin Koca of Turkey to be done the same. Turkish
people applauded at 9PM to show support to healthcare
professionals Figure 1. (BİA Haber Merkezi, 19 March
2020).
The President of the Istanbul Chamber of Medicine,
Dr. Pınar Saip said: “We are very happy. We reallyneeded this. The HCPs have been battling violence for along time. We were seen as responsible for changes in
the health system and the problems it caused. The
excessive intensity that we experienced was challenging
us; we were facing patients and their relatives. There
was humiliation and disrepute. Now with the 'applause'issue, it was once again understood that we are on thesame side.”
At an open-air meeting, HCPs asked for work andeconomic conditions to be improved, other thanclapping. Two of them were related to COVID-19 as
follows: All healthcare providers should have 1 test in 5days, and COVID-19 should be considered as a work
hazard, COVID-19 is an occupational disease (Duvar
Gazetesi, April 30 2020).
One of the doctors indicated that “this moral applausegives to us happiness. However, I wish that this supportshould not be limited to the timeframe that we faced theepidemic and breathed death. It should always be.”"Are the precautions taken for doctors sufficient?" Dr.
Saip' answer is clear: “There were patients we met
without realizing it. A pre-diagnosis before thediagnostic tests would have been more beneficial for
prevention. Every healthcare institution needs to takeaction for its employees. There is still a shortage ofprotective materials in many family health centers,
public and university hospitals. Hand sanitizers, liquidsoaps, and necessary protective materials must be
sufficient according to the work area. "If they do not
become permanent, if the healthcare professionals get
sick, then we may have difficulty in running theprocess"(Soybaş, 21 March 2020).

209

This support was meaningful for health workers, but
unfortunately,
violence,
stigmatization,
blame,
humiliation and disrepute towards health workers did
not end. People should think that COVID-19 cases haveincreased in a short time in Turkey, and HCPs haveendeavored to treat patients although their lives were at
risk.

Figure1. We applaud the health workers(Source: https://www.gazetebirlik.com/haber/uc-gun-saglikcalisanlarini-alkisliyoruz)

Stigmatization and blame: Stigmatization and blame
continued by celebrities, a governor and some people.
There were statements of M. Anlı encouraging “violence
to physicians”. M.Anlı targeted the doctors because she
was not given an injection! She wanted to have an
injection in the car. M. Anlı told her Tatlı Sert program at
ATV, that she went to the hospital due to migraine pain
and that she was not given an injection though she called
the doctor to inject in her car. However, the doctor
rejected her request and invited her to go inside thehospital. Anlı stated on her television show program,
after telling her story: "Then we say, doctors are not nice... then we close the hospitals"(Habervakti, March 30
2020).
Anlı's comments were viewed as clear violenceagainst healthcare workers. Following some statementsby public doctors, nurses and other healthcare
professionals working in the hospital that you do notwant to enter, and with the public’s opinion being
negative, Anlı apologized after receiving criticisms;
however, her apology was not clear.
A city Governor said: “137 of 567 cases were HCPs,
they could not protect themselves”. He spoke at a press
conference: “Normally we would be talking about
comeback today if it wasn't for the burden that ourhealthcare workers brought us. This was really difficult.
We hosted our HCPs in the guesthouse. We did not
charge for their meals. We also tried to provide themservices. But because they were not careful enough intheir relations there, they put both themselves and us indanger. They did not protect themselves, and they
became a burden to us as well" (A3haber, 17 April 2020).
After he was criticized for this statement he said
sorry. But still after that HCPs left the guesthouse they
were staying, allocated for them in order not to infecttheir families. However, they continued to provide
healthcare services, despite the risk of contamination
and being accused of getting sick. The above description

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

did not reflect the facts, because healthcare professionals
are serving patients with COVID-19, and the infected
person in question was detected late, since HCPs were
not tested frequently.
Healthcare workers were devotedly working in hardconditions because of the coronavirus. A dentist wasdismayed after seeing a message hanging at the entranceof his apartment building. In the message, which was
written on a piece of paper and hung at the entrance of
the apartment: “To the dentist residing in thisapartment, do not to touch the doors and stairwells
while entering and leaving the apartment (DHA, April 52020).
In Sinop, a site manager posted a decision that
healthcare professionals must use the rear elevators andnot the front elevators. Two female healthcare workers
living in the apartment answered the article with thenote: "Your discriminatory words break our working
desires. We are trying to treat you without
discrimination in the hospital while you separate us as ahealthcare provider. Even though you know that our
spouses are on duty abroad, we leave our little children
alone at home, and go to watch for you, yourdiscriminative attitude is far from solidarity and breaks
both our professional dignity and the determination towork. Your attitude is never acceptable in these difficultdays that the whole world should be in unity, solidarity
and solidarity. We will take all precautions to check inand out. Let the residents who are disturbed by this, use
the staircase option".
The warning letter of the site management that wasshared on social media was removed upon the reactions(Habertürk Gazetesi, April 7, 2020). The HealthCommunication Association President said: “Violence is
not just physical. Psychological and verbal violence also
creates a trauma as much as the physical one on
healthcare workers and doctors. Most of these people do
not go to their homes, they stay in the hospital. However,believing that returning home and seeing such an article
one evening is no different than a fist. ”(Soybaş, April 6
2020)
Unfortunately, violent incidents happen at various
levels and degrees such as insults, shouting, humiliation,and threats in hospitals which have become normal in
the health system. This attitude has also been adopted bysome governors of cities, celebrities and politicians
making the current situation worse. As seen in the online
reports above, the accusation, humiliation, and labelingbehaviors towards healthcare professionals who provide
healthcare services at the time of the pandemic continue.
Unfortunately, this attitude belittles healthcare workers
far from appreciating their value. It is important tointeract with risky patients and those who are concerned
about losing a much loved relative, and this pandemic
worsens the problem. The reports above reveal that thelack of communication skills is a fundamental problem
on all sides. Of course, the patient-physician relationshipoccasionally experiences communication problems.
However, a solution can be realized with improvementof the communication skills of the healthcare
professionals, as well as individuals who have influence
upon people whom can help solve the problem.
Healthcare professionals are not the one who bring
the disease; they try to treat the patient with serious

risks involved. However, this situation has been
reversed, and healthcare workers who have theknowledge and experience in the treatment of COVID-19
are perceived as ignorant-malicious persons and threats
are now being thrown at them.
Such events show that some people have a negative
perception against HCPs. Actually, the threat of theapartment manager included a hidden humiliation bothto HCPs and to medical education. As it is known,
infectious diseases threaten not only the patient but also
the healthcare team. It is known that many healthcare
workers have been infected while treating patients
throughout history. This undesirable situation
sometimes happens despite all the precautions.
According to the Ministry of Health, 7428 HCPs were
infected during the COVID-19 health service as of April
29 (Medimagazin, 2020b). This situation is not only inTurkey but also in all countries struggling with COVID19 (e.g., Israel, Italy, China, UK, France, Spain, Iran, theU.S., Greece, Poland, Pakistan) where many HCPs havebeen infected, and unfortunately some of them havealready died (Newsweek, 04.03.220).
Violence against healthcare professionals: Despite
new regulations violence against doctors and healthprofessionals continues. For health professionals in
Turkey, parliament adopted 'Violence in the Health Act',on April 15 2020. This law covers "deliberately injuring,
threats, insulting and resisting not to perform duty” in
the Turkish Criminal Code, committed against healthcare
personnel and auxiliary workers in public and private
health institutions and organizations. The penalties to be
determined according to the relevant laws will be
increased by half (Sayın, 2020).
In another case, S.A., who came to hospital with aheadache complaint, said that he wanted to be treatedurgently. Okan K., the doctor in charge of the emergency
room, told S.A. that his health condition was not serious,that the hospital was risky due to the coronavirus andthat his home was safer. Thereupon, S.A. punched thedoctor, and grabbed his throat (Medimagazin, 23 March
2020).
Another incident occurred in Samsun around 3:30
PM of 24 March 2020. According to the information
obtained, D.A. and his cousin Gamze K. went to Gazi State
Hospital. The secretary in the hospital cautioned themsaying, 'Just stay there' because of the coronavirus
measures. The cousins wanted to be examined by aspecialist but to no avail they were referred to thegeneral practitioner Z.K. where D.A. was examined.
When the doctor touched D.A. he exclaimed, 'You’rehurting me, what kind of doctor are you?' and he started
shouting. Meanwhile, Gamze K. started hitting Z.K's head,
which they squeezed between the examination table andthe wall (Figure 2). After the commotion in the room,
doctor Z.K. reported the incident to the police (İnan, 23
March 2020).
In another incident, the sons of a patient, who wastreated for suspected coronavirus, battered the nurse
and the security guard. The sons of the patient who wastreated in a private hospital with the suspicion of a novel
type of coronavirus (COVID-19) in Konya, A.A. and İ.Abattered a nurse and a security guard. The two suspects
were arrested and detained (AA, 2020).

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
Shocking images of the attack on the nurse who
struggled with the corona virus appeared in Izmir! D.Y.
wanted to report for her child. However, she did not giveher child's periodic report because she was not her
family doctor. Thereupon, Dr. D.Y., who went to thefamily health center where Akkus worked, allegedly
tried to head to the room of the nurse A. Kavuklu, who
was a witness in the case. Despite the interference of
health center employees, D.Y., who was walking on
Kavuklu, battered the nurse there. (Sabah Gazetesi,
04.04.2020).

211

investigation team's work in the field are evaluated by acommittee of public health experts. The last step is tokeep persons under investigations (PUIs) and/or
persons under monitoring (PUMs) for 14 days in a
hospital or in their house, to break the chain of thepandemic. This method leads to early diagnosis of
COVID-19 patients or suspects, helping to start
treatment at the initial stage of the disease.
The field investigation team provide important
information such as whether the danger still continues
and whether other people are at risk can be obtained.
Therefore, this team is taking a crucial role in fighting all
infectious disease, and so it makes the fight against
COVID-19 more effectively. The violence against field
investigation team who are in the riskiest position groupin the coronavirus epidemic and who lost many of theircolleagues is not ending. One of the field investigationteam members A.I. and B.A. with the driver of theinstitution, were attacked on the street on their way tothe field investigation house in Bursa (Duvar Gazetesi,
April 29, 2020).

Figure :. Girls attacked the doctor (Source:

https://www.sozcu.com.tr/2020/gundem /genc-kizlardoktora-boyle-saldirdi-5711625/)

A doctor, who was attacked by the patient’s relatives,
rebelled: I'm afraid, do you hear me? Doctor EE. Genç,who worked at KTÜ Farabi Hospital, was attacked after apatient with lung cancer and breathing difficulties died.
They entered the COVID-19 ward, with masks andoveralls, waving their hands and kicking left and right,
over the patient who passed away. Sharing her fearful
moments from her social media account, Doctor Gençsaid, "What will happen next time, will I be able to returnhome to my family? (Figure 3). I don't know” she said
(Akduman, 2020)

Figure 3. "I Don't Feel Safe" (Source:

https://www.bursa.com/kendimi-guvende hissetmiyorum n425090/)

There was an attack against field investigation teamon the street. The Ministry of Health formed an“infectious diseases and fighting guide (Regulation
22/2018)” to prevent and reduce infectious diseases(T.C. Sağlık Bakanlığı, 2018). The field investigation
team’s first aim is to find the source and the effect after
the notification of the case and/or taking protection andcontrol measures including the contacts. Wearing
protective overalls, masks and gloves, the team goes tospecified addresses and takes samples from the people
to be tested. The teams deliver the samples they take tothe reference laboratories. The results of the field

Figure 4: the field investigation team (Sourse: Duvar
Gazetesi, April 29, 2020)
There was also an alleged 'threat to death' to a family
doctor in Izmir. In a statement made by the Izmir
Chamber of Medicine the person was invited to thefamily health center for his child's vaccinations. The
family physician explained that vaccination procedures
were carried out while maintaining social distance.
However, the family physician was threatened withdeath by child’ relatives for having to wait in line (AAHaber, May 2 2020).
It is seen that the accusation against healthcare
professionals and the violence continues and remains
unchanged. It may be thought that the psychologicalbalance of the society is affected by the deterioration ofcoronavirus, but there was violence towards healthcare
professionals even before the coronavirus. Meanwhile,the law for prevention of violence in healthcare has
finally been adopted in the period of COVID-19. This is agood development, but in the law, delays in thepunishment of the violator against healthcare
professionals will reduce the impact of this law. In fact, itis necessary to determine a serious policy for theprevention of violence throughout the country and to
implement it seriously. In order to eliminate theproblems brought by the system, this system needs to berevised.
The commercialization of health undermines thecommunity's trust in the country's health system. Citizen
M. Güleryüz said, "I had a cough for two or three days.
My cough did not pass. I went to a private hospital for
the COVID-19 test. It was the nearest hospital to me.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

They demanded 476 dollar for the test. There was acontroversy over it. Güleryüz, who went out with anger,
tried to enter the hospital door with his vehicle (Yeniçağ
Gazetesi, 29.04.2020).
The COVID-19 pandemic forces a decision on citizens
as private hospitals should not request examination fee
and additional surcharge from patients undergoingtreatment. However, as seen in the case above, COVID-19
test was not included within the scope of this ministry
and a serious fee was requested.
In this context, complains against private hospitals
were made in the past due to many violations. The
inquiries have been opened for many hospitals, as manyof these private hospitals have asked for unnecessary
tests or examinations, and the strategy of increasing thepatient's income seriously damages both the patient andthe state such as 10 percent of cataract surgeries areunnecessary. After a fake treatment to the father of thepresident of the Social Security Foundation, in private
hospitals an investigation was opened into the private
hospital, because these hospitals used the identity offormer patients to get the minimum wage (Medimagazin,
2020a).
Briefly, the commercialization of the healthcare
system affects many private hospitals, and raises new
problems and harm on health equality.
Limitations of study
The present study data were collected from online
Turkish newspapers by Google research engine and also
from web sites such as Ministry of Health that takeofficial regulation into consideration. Collected reports
were taken by key words between March 11 and 30
April 2020. These reports were discussed in the public
and on social media and made in some judicial
proceedings. Of course, online report can be evaluated invarious ways in different contexts or interpretation.
Acknowledgement
I would like to thank all healthcare professionals who
continue to provide healthcare services with ethicalattitude despite some negative backlash and the COVID19 outbreak and also to journalists who continue toreport the facts.
Conflict of interest
None
Conclusion
This study is about stigmatization and violence against
HCPs in Turkey during the COVID-19 pandemic. This
world crisis has seriously exerted great pressure on
healthcare facilities and healthcare professionals, andsociety. Although healthcare professionals havepresented healthcare service in the frame of the
Hippocratic Oath, Medical Deontology Regulation,
medical and public health ethics, and patients’ rights,
they have encountered stigmatization and violence.
Stigmatization is an urgent issue because it triggers
some negative perceptions such as prejudice,discrimination, and negative stereotypes. These
perceptions cause the stigmatized people to be subjected
to various acts of violence.

The online reports events included in the study prove
this situation. Therefore, stigmatization should beconsidered as an urgent issue and a serious and feasible
policy should be developed to prevent stigmatizationand violence. In this way, we can protect the healthcare
professionals who are committed to protecting andimproving the public health, and therefore the society.
We should endeavor more to remove violence in healthfrom the agenda in Turkey.
References
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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
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213

Dabawenyos helping Dabawenyos in a
spirit of Bayanihan: CSOs and private
persons’ works of compassion during
COVID-19 pandemic- Erikka June D. Forosuelo
Cor Jesu College, the Philippines
Email: erikkajunedecrepito@gmail.com- Rogelio P. BayodCor Jesu College, Email: roger.bayod@gmail.com

Abstract
During emergency situations, cooperation among themembers of the population is of great importance. Asidefrom the government leaders and officials who are
expected to reach out to the affected populace, Civil
Society Organizations (CSOs) and private individuals in
Davao Region have been doing their works ofcompassion to provide the needed assistance tocommunities and individuals who are mostly affectedduring disaster and emergency situations. In fact, ourworks on the ground can attest that a lot of concerned
people who felt the burning desire to render help would
rather give their donations to these groups because they
are assured that their assistance will certainly reach tothe most affected families and individuals in thecommunity. This paper tries to examine the different
roles of engagements played by the Civil Society
Organizations (CSOs) and private individuals to help
those who are mostly affected during this Covid-19
pandemic. Drawing from their insights as well as fromthe available literature on the roles of CSOs and private
individuals during emergency situations, this paper willargue that CSOs and private individuals in Davao Region
have been very active not only in doing concrete works
of compassion on the ground but also in challenging
other stakeholders to take part in this work ofcompassion including the government leaders toprioritize compassion over their political ambition. It
will then argue that the success of any intervention
during emergency situations often depends on thecooperation of the members of the population.
Introduction
Civil Society Organizations (CSOs) continue to play animportant role in the field of disaster management
especially in disaster response and relief (USAID, 2019).
In the case of pandemic situation such as Covid-19, CSO
has the potential capacity to largely contribute to hasten
relief operations through their active collaboration withprivate persons who are more than willing to sharefinancial resources and voluntary services to address theimmediate need of their fellowmen in times of calamities
and disasters. What bring CSOs and private persons
recognize the significance of community-based
assistance in order to support local government effort to
distribute relief goods during quarantine periods?
“Compassion is like a baton in a relay race. People will
always pass it on.”—Datcher Keltner as cited by Girod,(2019). Majority of us have experienced acts ofcompassion as it has been manifested to us or as we haveexpressed it towards others. Girod (2019) mentionedthat “Compassion is not just a one-and-done job.
Compassion is an ongoing expression of sympathy and214

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

empathy for a person who has hit a rough patch in theirlives”. This can live within us and it is contagious
because it will motivate other people to do the same.
Compassion is a chain reaction; it can be passed on fromone person to another until everybody is doing it. It canalso change a person’s outlook in life including his or her
responses given a critical and difficult situation. It is said
that character is tested not when all is well but in thepresence of adversities.
Dabawensyos are very active in helping each other inthe spirit of Bayanihan especially during disasters andnatural calamities. This act of volunteerism was very
evident when our region was hit with series ofearthquakes last year. As one of the early responders
who reached out to the most affected individuals andcommunities, we saw Mindanawons helping their fellow
Mindanawons (Bayod, 2020). In our experiences thistime with the Covid-19 pandemic, we witnessed thesame act of kindness through people rising up andvolunteering and reaching out to individuals (poorpeople, students, front-liners) who are in dire need.
Instead of sulking in quarantine, these people decided to
be productive and became channels of blessings toothers who are in need.
In this paper, we would like to mention them (withtheir consent already sought) and their undertakings
during this pandemic. What motivated them to reach out
to people? Who have been their companions in thismission? What were the challenges they’ve encountered?
What are their insights and also recommendations?
These are the questions that we asked to them and in
this section, we will narrate their answers that wealready clustered into themes.
Motivations of Dabawenyos to help other
Dabawenyos
Since we already witnessed these people responding todifferent crisis situations, many of them were ourpartners and companions in the community outreachactivities that we had conducted. We asked them what
motivates them to repeat what have been done in theprevious volunteerism acts and relief operation
initiatives to be able to reach out to people andcommunities in need of help, given a different scenario
which is very challenging because this time, we arefacing with the invisible-Covid 19. According to Janus &Misiorek (2019), ‘‘Volunteerism’’ denotes helping others
without expecting ﬁnancial rewards. Volunteering is an
important social behavior, needed to sustain civil society(Cnaan and Park 2015; Smith et al. 2016). Volunteerism
usually occurs in the context of an organization, whichmeans that it is performed under the auspices ofparticular entities (Finkelstien 2009). In the findings ofthe study of (Naqshbandi et.al, 2020), social aspects ofthe volunteering experience are grounded in the interpersonal relationship between the volunteer andbeneficiary. This implies that people or group ofindividuals are motivated to help because they can feelthe sense of relatedness especially that they belong to
the same region and they too, experienced similar plightof the pandemic. Additionally, based on the result of thestudy of Janus & Misiorek (2019), the rewarding factor
which became part of the volunteers’ motivation toextend help was, ﬁrst and foremost, doing good. This isaffirmed by Yamashita, Keene, Lu, & Carr (2019) on therelationship between motivations and actual interest involunteering, which is arguably a more proximate
predictor of volunteer behaviors. This indicates thatmajority of our informants perceive the act ofvolunteerism as doing good which motivates them tohelp without asking anything in return. As a matter offact, we were amazed and the same time affirmed bytheir answers. Their motivations to help those in needduring this pandemic situation are: family values andupbringing to be persons for others, to put flesh and maketheir faith and spirituality alive, sense of empathy to thosein need and also their sense of gratitude to the frontliners.
Family values and upbringing to be persons forothers. Family values and upbringing to be persons forothers inspired many Dabawenyos to reach out to theirfellow Dabawenyos. Richaud and Rodriguez, (2020)
mentioned that when warm and nutritive relationships
have developed with parents and friends duringchildhood and adolescence, this motivates the tendency
to help and comfort them in various circumstances oflife. This indicates that family plays a vital role in
influencing the children to develop the motivation to
help others in times of need because children believethat if they see this act of kindness in the family where
they belong, they will learn that it is innate to them andthat eventually, they too will do the same for others. For
example, Atty. Genevieve “Bebang” Brandares Paulino
who is the Dean of our Law School Department narrates
how the teachings and values of their parents inspired
her to organize a task force to respond to the needs offront-liners, students and others. In our conversation
with her, she narrates the roots of her compassionate
works:“I was brought by parents who taught us theimportance of serving others, especially the lessfortunate. SoI started with giving food, masks, PPE
SUITS, face shields to hospital front liners. But because
other front liners, like the policemen manning thecheckpoints requested for PPES too, I asked my clientsand friends abroad to help me. Then I learned that
there were law students who are residents of far-flungplaces who were stranded in Digos. They could notcome home to their respective places because of the
lockdown. So, I organized a Task Force in the law
school to help address the problems and needs of thestranded students”
This was affirmed by her sister, Mrs, Bernadette
Brandares Aves, who works as a college professor in our
school. She reports:“In our family, the Brandares family, we have been
inspired by the examples set by our parents to share
our blessings to those in need whenever there is an
opportunity for us to share our blessings. I and Bene,my husband together with our children alreadyplanned to share a little amount. So when I saw mysister Bebang in Face Book, donating PPEs to thefront-liners, I told Bene and my children that we will
also donate a little amount to Bebang’s initiatives. My
children gave also out of their own allowance”.
Other informants also shared how much their family
inspired them to be generous to those in need. One of us

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
who asked not to reveal her name says that she was
moved by the values taught by her parents.
To put flesh and make their faith and spirituality
alive. Interestingly, all of our informants in this study arepracticing Christians. Thus, they want to put flesh inorder to make their faith and spirituality alive by doing
concrete works of compassion during this pandemic
situation. One informant in the person of Br. Noelvic
Deloria, SC, a member of the Congregation of theBrothers of the Sacred Heart and who also works as aschool administrator in one college in Davao City has
these words: “Who knows by this simple gesture, “ourunselfish and dedicated concern can reveal to them(people in need) the compassion of the Lord and draw
them to him.” He adds that “another motivation is thesense of mission during this time of crisis”. Religiosity
may contribute to individuals’ sense of purpose (KornasBiela, Martynowska, & Zysberg, 2020). Our religious
belief and the teaching we learned from the church give
us an inspiration to perform noble acts for others. It is in
this context that we enliven our ultimate purpose in lifethat makes our spirit satisfied and happy because wehave extended help to people in need. This is also themotivation of Nonito “Dondon” Llanos, III, a Philippine
Red Cross Volunteer who had been very active in doing
volunteer service during the series of earthquakes andalso during this Covid-19 pandemic. Atty Genevieve
Paulino says:“As a Christian, the passion to be or service to others
and the call of volunteerism were instrumental ingiving me courage to continue extending help to myfellowmen in spite of the health risk which goes with
it. Indeed, difficult times reveal our true character.” I
have always believed that faith without action is dead.
Our motto is, ‘Putting our money, where our mouth is.’In short, walking the talk or practicing what we
preach. It has been a way of life.”
Helping others and doing volunteer services make their
Christian faith alive and operational.
According to Łowicki, Zajenkowski, & Van Cappellen,(2020) empathic concern is primarily associated withreligious belief. This reveals that there are people whotruly practice what they learned from the religious
teaching and they are doing it unselfishly, not asking
anything in return. Thus, to them, it is considered joy andlife fulfilment when they are able to give help. For BethDel Fierro, who has been doing a lot of missionary works
in Mindanao for the last 20 years or more, she ismotivated by the Golden Rule and her love of God:“the Golden rule has always been my guide in
everything I do. My love of God is my greatest
motivation to help others in need. While participatingin the circle of friends who are doing missions in the
ground, I also packed rice and other basic stuff to giveaway whoever comes in our house and ask for food.”
Anther informant is inspired by the Church teaching
to help the lost, the least and the last in the society. “I amalso moved by the teachings of the church to be a
responsible citizen by helping those who are least, lost andlast.” The experiences of our respondents affirm thestatements of Hyun et.al, (2020) that Christian Education
is not only giving lectures or setting God's commands but
providing solutions and disciplines that can put faith into

215

real students’ life. Perhaps the teachings of the church
are successfully instilled to the learners until such timethat they found a venue to practice what they havelearned in the real life setting, wherein help, assistance,
aid are concretely embodied through the spirit ofvolunteerism, wholehearted giving of donations andparticipation in relief operations. Thus, Religion is astrong correlate of a majority of forms of social
involvement and a strong predictor of volunteerism andphilanthropy (Putnam 2000). According to Priyanka andSmita (2018), religion is closely related to altruistic
activities.
Sense of empathy to those in need. As we go along with
our discussions with them, we found out that theirfamily upbringing as well as their faith and spirituality
were influential in nurturing their sense of empathy
which also motivates them to reach out and help those in
need. This is beautifully expressed by our informant
when she said:“I felt the need to respond in this time of crisis because
I imagined myself and my family if put in a situation
where basic necessities are scarce, no salary and nomoney, while daily needs are eating up the day to day
consumption. I know what it is to be in need, so I am
sensitive to take action in my own little way.”
Also, as discussed by Lopez (2019), people werecompelled to help based on a high level of empathy they
were feeling. This is also the motivation of Marianne
Eve Sanchez, our former student leader who works as asupervisor in multi-national company when she said:“to know how it feels to have nothing to put in thetable is what motivates me to respond to thispandemic situation and be able to extend help in any
ways that I can”.
She was brought to feel the needs of others to respond to
it in any way she can because she feels how it feels tohave nothing. For Noetel et al., (2020), donating tosupport effective solutions to needy causes is motivating
for many people. This holds true to our respondents
whom, apart from imagining their own selves in theshoes of others who are in need during this time ofpandemic, donating both in cash or in kind can be among
the best and immediate solution to the crisis. Jeanette
Albios who works as a caregiver in Singapore had been
active in sending help to her neighbors during thispandemic also. When we asked what motivates her to beconcerned about her neighbors, she replied, “only one
thing motivates me to respond to this pandemic situation to be able to help those in need because as a poor, I know
how they needed support in this situation.”
Sense of gratitude to the front-liners. Most of thesepeople gave quick assistance to the front-liners and lateron, they expanded it to the rest of the members of thecommunity. When asked why they immediately reached
out to the front-liners, they said that they want to show
how grateful they are for the sacrifices of these frontliners. One of them, Br. Nolevic Deloria has these words:“We salute the front-liners in the SPMC hospital because
they are the most vulnerable to being infected. In fact a
number of them have already succumbed to the deadly
N-Corona Virus. The housekeeping personnel are also
very vulnerable. The morning shift is 148 persons,

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

afternoon shift is 78 and evening shift is 73. Some may
receive food packs but we know that they are the lowest
paid among the front-liners, and therefore, they might
not have extra money to buy more than what is given tothem. So we thought of augmenting their meal by giving
them at least one viand, and we try as much as possible
to offer them nutritious food, thinking that they are
doing so much physical work in keeping the hospitalclean and well-sanitized; notwithstanding, the psychoemotional stress of the whole situation of this pandemic.
We would like to help in keeping them healthy andenergized to fulfill their duties and responsibilities.”
Dabawenyos helped their fellow Dabawenyos to let themfeel the love and care during this time of pandemic.
Those who reached out to them were inspired by theexamples set by their parents, their faith and spirituality,
and their sense of empathy and also to express gratitude
for the sacrifices of the front-liners. Others were also
inspired by the call of President Rodrigo Roa Duterte(PRRD) for Bayanihan during this time of crisis (Garcia,2020). As emphasized by Pal, 92020), gratitude is likegood will. It has no substitute. It only shows that despite
the difficult situation, people who extended their help
did not forget that they are indebted by the fact thatwhile most people stay in their respective homes, others
leave their families behind because they are frontliners,
the persons who have close contact with people because
it is their
Who were with them in this Mission?
We know that there are many people behind them who
also helped them. We wanted to know who they are andhow they approached and inspired them to be part in the
mission. For most of our informants, their families andfriends (here and abroad) were with them and helped
them in their endeavors. This was also our experience
before during earthquakes; we have friends and relatives
abroad who sent us money for our relief operations. It isvery different this time because Covid-19 affects thewhole world. Community quarantine and lockdown werealso implemented in most countries throughout theworld which made it more difficult for our friends andrelatives to send money. However, despite this scenario,
there are still friends abroad who help our informants intheir works of compassion. The social media, especiallyface book was very useful in contacting generous
persons to take part in the mission. According to Br.
Noelvic Deloria, SC: “the social media has been very
helpful in spreading the good virus to help. I posted the
project on facebook and many friends of good will
responded, some were already our partners in mission,and new ones were joining.”
Social Media had been very helpful in creating networkof helpers. That is why Atty. Genevieve Paulino says: “Ihave no qualms in posting the help to others in Facebook
not to advertise or for self-promotion but because. I WANTOTHERS TO KNOW THAT THERE IS SUCH RELIEF
EFFORTS BEING UNDERTAKEN. In this way, they too will
be motivated to help. Further, it is by posting in social
media that that the donors or benefactors will see where
their money is going.”
Social media is also being used for transparency. A lot ofdonors would rather give their share to Civil Society
Organizations because they are assured that their help

will really reach to the intended communities. For
Dabawenyos, inviting others to take part in “Bayanihan”
mission of compassion is not difficult. In fact, according
to Beth Del Fierro:“It doesn’t make a sweat when you pray and ask God
to send friends with golden hearts. We are calling eachother and right away get connected . We do believethat if there’s a will there’s a way. My friends andfamily who witnessed our missions especially mynieces and nephews who are now in business and mostof them are in the medical fields are the ones
spearheading the fundraising and looking for the
supplies.”
Anther informant also says:“I also have with me my student leaders whose
leadership abilities are innate to them that’s why even
without contacting them, they wholeheartedly
volunteered.” Mrs. Bernadette Aves adds, “Aside frommy family, I also encouraged my former BSBA students
to share their blessings. I posted it in the JEBA Alumnigroup chat”
For Br. Nolevic, his community, The Brothers of the
Sacred Heart were his first companions in his mission,“first, I have the community of Brothers. I asked for an
emergency meeting in April 2020, right after lunch todiscuss the possibility of the food mission. The Brothers
responded quickly and we organized ourselves according
to tasks, duties and responsibilities.”
It is clear that the Bayanihan spirit is very much aliveand present among Dabwenyos (Bayod, 2020; Garcia,2020). We even witnessed that people are willing tosacrifice so that others may also have their share. The
Bayanihan spirit is one of the values of social
relationship which according to Bernardo (2019) is thespirit of cooperation and how it eases what might be aheavy burden for one person. It is true that Covid-19
affects everyone in the country and the whole world, andamidst this trying time, we can still witness acts ofkindness of our fellowmen. While in some parts of thecountry, people have been complaining about not being
included in the Social Amelioration Program (SAP) of thegovernment, in some parts of Davao region, especially in
Davao del Sur, there are some qualified beneficiaries of
SAP who refused to get their share and instructed theDepartment of Social Welfare and Development (DSWD)
personnel to give their share to the most needy. We also
know of one Barangay (village) in Davao del Sur in which
their Barangay Captain (Village Local Chief Executive)
gathered his constituents and agreed among themselves
to share the funds and the food packs equally to all towhich the residents also agreed. However, we are notsaying that there are no complaints. We believe there are
but these can be pacified immediately because of the
Bayanihan sprit of the local communities.
Challenges they encountered
There are always challenges in doing missionary works
to communities. But during emergency situations, there
are more challenges that responders in the groundencountered. This is attested in the findings of the studyof Arcega (2019) that the challenges encountered by
student leaders in different volunteered activities were
high. These group of student volunteers also experienced
problems while they participate in different volunteeringEubios Journal of Asian and International Bioethics 30(5) (June 2020)
activities. However, regardless of the different problems
they encountered, the Bayanihan spirit which is a
Filipino value unleashed their passion, commitment, anddedication to contribute huge impact to theircommunity. In the case of our informants, the challenges
that they encountered in their mission are the following:lack of human and material resources, difficulty inlooking for supplies, and information dissemination.
Lack of human and material resources. In ourconversation while going to the communities to
distribute the food packs and to talk to our affectedstudents, we realized that during disasters, calamities
and pandemic where everybody becomes a victim, we
just can think of “if only’s”. If only we have more thanenough, we could have extended more help; If only there
are lots of volunteers who are with us, we could havemobilized faster. This pandemic brought a lot of humanactivities into a sudden halt. We cannot go put easily as
we can. We really need to bring our quarantine pass tobe granted permission to travel to communities to
distribute some goods. As confirmed by Asefa, 92019),
the major challenges of relief operation are poor
inventory management practice, lack of coordination andcollaboration among players in the relief operation, andinadequate funding. These are also the experiences of
our informants. Nonito “Dondon” Llanos, III of Philippine
Red Cross shared with us that:“the biggest challenge we had personally encounteredas Red Cross Volunteers was the limitation of ourresources as most of our programs and activities
solely depend on donations given by benevolent
individuals and groups.”
While Dondon Llanos talks about limitation of material
resources, Br. Noelvic Deloria talks more about humanresources. Br. Noelvic says.
“Because we also have other responsibilities here in
the house, we perform work from home, formation isgoing on, and the work of a superior continues with orwithout Covid. Even if we have a number of individuals
who expressed themselves to volunteer, we could not
accept them to fulfill the ECQ guidelines. We limit
people coming in to our community. So much as we
wanted to do it every day, we committed ourselves to
do it ta three times a week, specifically Monday,
Wednesday and Friday.
To serve the 299
housekeeping personnel, we divided them into twogroups, Group A – 148 Morning Shift, Group B – 78
Afternoon Shift and 73 Evening Shift, and we do it
alternately. When the ECQ was heightened and there
was already a limit to the days when the Food
Medicine pass can be used, like I can only go out
Tuesday, Thursday and Saturday (TThS) according to
my code number, but our commitment is Monday,
Wednesday and Friday (MWF) with the SPMC. So I
asked for a special certification from SPMC that I may
be allowed to pass through checkpoints as food donor.
Considering my other tasks and the need to have somegood rest, I just have to optimize the use of my time.”
For Marianne Eve Sanchez, her work in the company
hinders her to really be active in doing volunteer work in
the ground. “Because of my limited time due to a full work
week schedule and I cannot easily perform my intent tohelp such as volunteering”

217

Difficulty in looking for supplies. Another challengethat we faced in the ground is the difficulty of looking for
supplies such as face masks, alcohol, hand sanitizers, andother grocery items. This has been the experience of Ms.
Jeanette Albios who is based in Singapore and who justsent money through her friends to buy some goods forthe community. She says that her challenge is “of looking
for the groceries and rice for relief goods for my neighbors
because in my place that time mostly not available.” Thisis also the experience of Atty. Genevieve Paulino. Having
plenty of contacts, she says there is “not so muchchallenges, except for the delay of the suppliers indelivering the PPES because of lack of supply. We also
encountered this in our own groundworks but
fortunately in the place that we operate, there are plentyof individuals who share their vegetables, eggs and otherstuff to be included in our relief operations so we did notencounter much about this.
Information dissemination. As to information
dissemination, this challenge is specifically mentioned by
Br. Nolevic Deloria, SC but not mentioned by otherinformants. How does information dissemination
become a challenge for Br. Noelvic?
“I think it is important to keep the donors andsupporters informed, so that they would know how
their money is spent. So I became active in posting theactivities in the social media and to spice up a little bit
the reporting, I made stories (Legend-like: about how
the five chicken sacrifices themselves to become
Chicken Afritada, and the marriage of Can Ton andSotang Hon and eventually had their baby Bam-I, or
Featuring somebody, like our cooks, and the people
behind the mission) with a lot of pictures on how thecooking was made, and pictures of the recipients ofthe food at SPMC.”
This might be very challenging to him considering that
he has plenty of work assignments and he still delivers
the food to the hospital. But he needs to keep his donors
and the public informed about what has been happening
with their mission.
Their insights about the mission
When asked about their insights, most of them sharedthat helping is a culture and therefore, it must be a way oflife, it is good to be a cheerful giver and to make adifference to the lives of others.
Helping is a culture and therefore, it must be a way oflife. Majority of them said that help should not impose as
it must be coming from the inside. This is frankly sharedby our informant:“I believe that helping is not imposed. It has to comefrom the heart. If we have the heart to empathize, thenwe learn to put ourselves in the shoe of people who
struggle for their everyday needs.”
This informant is very Kantian in her approach to life.
For Kant, every person knows the moral good and is selflegislating. Thus, his actions must be free from externalinterreference or factors (Kant, 2002).
For Atty. Genevie Paulino, to help is a way of life
because this is love in action. She says:

218

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)“we always profess our love to an invisible God. How
can we say that we love God if we cannot even express
our love to the less-fortunate? That love can become
concrete and evident if we help the poor. That is lovein action.”
This is affirmed by Byrne-Jiménez, & Yoon (2019)emphasizing that love is an energy that emanates fromwithin to shield and care for others.
Be a cheerful giver. For most of them when you help
you must have a happy heart because this is theexpression of your love. In fact, for Marianne Eve
Sanchez, “there is no limit to help especially in this time ofcrisis. Small or big, as long as it is done with warm andsincere hearts, it matters”. Another informant also
shared her insights:“I realize that in this time of ECQ, when my family and
I are staying in our home and we have enough, I am
motivated to share our blessings to families who are
more affected in the pandemic. It is bigger than agrand lotto jackpot looking at the happy faces ofpeople who were able to benefit of the noble
endeavor.”
Atty. Genevieve Paulino added, “It is always good to help.”
For these informants and for others, there is joy ingiving. We also experienced this in our works evenduring earthquakes and this time of pandemic. Despite
physical tiredness, our spirit remains very much alive.
According to Show (2020), people give tithes withwilling and joyful hearts. This is highlighted by Paul whosays in (2 Corinthians 9:7) “Each one must do as he has
made up mind, not reluctantly or under compulsion, for
God loves a cheerful giver”. Indeed, there is joy in giving.
We are invited to be a cheerful giver.
Make a difference in the lives of others. Marriane Eve
Sanchez says, “in this trying times, it is very importantthat we become part of the solution rather than the
problem.” It is always good to make a difference to thelives of others. While a lot of people have become cynicalabout the situation, others remain to be positive andthey would like to radiate this positivity to others. For
Nonito “Dondon” Llanos, III, this is a time to really makea difference to the lives of others. He even quoted
Vatican II in saying:“as the old adage aptly puts it “no person is too poor,
not to give something and no person is too rich not toneed anything”. This made me realized that we are allconnected in this cycle called “life” and it is up to us todecide how we will make use of it. If we use our life to
make a difference in this world, then we can say, we
are rich beyond measure.”
For Jeanette Albios, we can make a difference byalways choosing to help, “if you know yourself that you
can help in this kind of situation or problem don’t
hesitate to help the people especially those in need.”
People have a sense that life is meaningful when theyexperience purpose, significance, and coherence(Steger, Frazier, Oishi, Kaler, 2006). Morse, O’Donnell,
Walberg, & Dik, (2019) said that meaning in life isconsidered to reflect an individual’s subjective, global
sense about the nature of her or his existence. This istrue in the aspect of helping others because this meansthat individuals chose to create meaning out of their

existence by making a difference in the lives of thepeople with whom they extended their assistance andact of kindness.
Their advice or recommendations to other CSOs andto the politicians. We also asked them about theiradvice or recommendations for other CSOs and also
politicians who are expected to do their part during thistime of pandemic. For them it is good that CSOs andpoliticians should embrace giving as a way of life and forpoliticians to stop politicking during emergency
situations such as in Covid-19 Pandemic. As emphasizedby Larruina, Boersma, & Ponzoni, (2019), realpossibilities for CSOs and local GOs to work together.
This can be possibly achieved because municipalities andbarangays are a lot smaller and are less bureaucratic ascompared to the central government. In this way, there iseasier and faster mobilization in terms of distribution ofrelief goods and other important human services needed
during pandemic, disasters on natural calamities.
According to Jeanette Albios: “my recommendation forother persons who are doing Humanitarian mission
during this pandemic is “don’t stop to help people in need.
If you know one person who is in need, just give help.”
For Nonito “Dondon” Llanos, III this is the time that wegive hope to others. He says: “to other private individuals
sharing the same calling as especially in the field of
volunteerism and public service, may our hopes continue
to flicker in this difficult time and may we always havethat burning passion to be a person for others.”
Another informant directs her recommendation to thepoliticians:“for political leaders, this is not the time of“politicking”. This is the time to work as a front-linersof the people in your jurisdiction. This is also the timeto prove that you deserve the vote of your constituents
who trust your capacity to become change agents andbe the very first to respond in times of difficult
moments like what we are currently experiencing.”
Whether emergent or established, CSOs assist refugees
through advocacy, the provision of extra services, andthe help of volunteers (Fleischmann & Steinhilper,2017).This is in the case of other countries when people
lend a helping hand by sincerely donating through cash
or in cash in their own capacities. It implies that CSO
plays a very important role in linking the basic services
in the community in times of adversities. According toVaughan & Hillier(2019), “local service provider CSOs
are the first to respond when disaster strikes, and often
are the only actors able to access some areas withinfragile and conflict-affected states”. At some point, these
private groups are often the first to respond, and thenlater on government organizations come into the picture.
We would like to highlight the recommendations of
Br. Noelvic Deloria, SC here because we found them verymuch applicable not only during this pandemic but inany other forms of community engagements that
individuals and groups will do in the future. He shares
seven recommendations. Just like the seven gifts of theholy spirit if these will not be taken seriously, it will
result to seven woes. Thus, it is good to be remind by thefollowing:Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
Context/situation mapping. It is important to know thecontext: the needs, the processes in the system, in thiscase, the SPMC), who to contact, etc.
Survey of available resources. Before we commit
ourselves to respond to the need, we check on ouravailable resources, material and human resources,
identify gifts and talents of individual persons needed tocome up with an organizational structure that is going towork. A group of people must be involved who areconvinced of (bought into) the particular mission; that it
is worth taking.
Realistic planning and designing. If we feel confident
enough to respond to the need(s) given the resources wealready identified, we determine the desired reality or
output, and dream-design how it could still be more
effective, efficient and energy-giving, in a way, that thework become inspiring and life-giving first to the doers
and then to the recipients.
Strategizing. We need to strategize how things be given,and continuously evaluate and listen to feedback, andinnovate the process and the product, accordingly.
Apply praxis paradigm: action-reflection-action. We
just do it and not to be trapped into “too-much planning”,
keeping in mind that this is not our mission, but we arecooperating with God that His mission be fulfilled. We
do our work with dedication and commitment but it is
God who blesses it and make it continue if He wills it. I
do believe doing mission work like this, it is importantthat I always anchor myself on God; that He will send us
the right persons, after all, as I have said this is His
mission. We might make plans, but we make them pliant
and fluid, rather than be constrained only to what has
been planned as if cast in stone. Innovations andcreativity make the mission more interesting andinspiring because we participate in the creation of a Godreality. We also allow ourselves to commit mistakes, tofail, but we also make sure that we take responsibility on
our actions and decisions, and learn to rise up again andmove forward. And if it is the time to end… it is the timeto end.
Engage the community into crucial conversation. We
continue conversing with the key people to keep theactivity on track or to add on to what has already been
made without losing what is essential, and the essential
is how to make God’s mission into fruition. We bring in
more people to be part of the mission and let them feelthat their stake was not wasted.
Information
dissemination is important for transparency, andconsequently, for a deeper and wider support.
Be grateful. Always be grateful for everything is grace.
We must not forget that we are not “the grace” but weare only channels of the grace of God. As I have alreadysaid it, we bring in more partakers of the mission, so it is
a community that celebrates, not only I, me and myself…
alone or our own elite group, for truthfully when one
celebrates alone, he can easily be intoxicated by vane
glory. By being grateful with the small successes or evenwith the learnings brought about by so called failures,219

we can continue to be a positive energy to others, andthis positive energy continues to radiate even without us
knowing it. I am indeed grateful because through thismission we have made our conviction as Brothers of the
Sacred Heart concrete, “to believe in God’s love, to live it
and to spread it,” especially in this critical time. And, weare truly humbled by the people who believe in what weare doing and who have supported us in many different
ways.
Conclusion
The spirit of Bayanihan in the Philippine setting is part of
the Filipino culture. People from different walks of life
especially the Dabawenyos helped one another because
they are motivated by strong family values, sense of
spirituality, and more so sense of empathy and gratitude.
This noble deed spread through fellow Dabawenyos who
are also companions in mission, some are proud student
volunteers and others are ordinary citizens who have theheart to help in times of calamities, natural disasters andpandemics. This paper finds that despite the various
challenges faced by the Dabawenyos in their desire tohelp such as lack of human and materials resources;difficulty in looking for supplies and information
dissemination in terms of informing the donors on theproceeds of the cash and in kinds they donated, still ourhelping hands were able to find very good insights intheir works of compassion in this Covid-19 pandemic.
Majority of the informants consider their noble
endeavor simply as a way of life; they become cheerfulgivers and most importantly they make a difference tothe lives of others with whom they helped. When we sayworks of compassion, it comes from the heart, it is ingood faith. Crisis and disaster studies haveacknowledged that citizen volunteers play a major role
during crises (Drabek & McEntire, 2003; Helsloot &Ruitenberg, 2004; Schmidt, Wolbers, Ferguson, &Boersma, 2017).
While there are always goodSamaritans in times of pandemic, the CSO and thegovernment, as represented by the elected national andlocal officials, should work hand in hand to serve thegeneral public. “The importance of citizen involvement
can be seen when citizens converge to assist in damage
assessment to provide general support to the GOs(Government Organizations)” (Kendra & Wachtendorf,
2003; Schmidt et al., 2017).
The ultimate goal of the “works of compassion”, of“help” in situations that the Covid-19 brought to all of us,
is to be able to feel the need of our fellowmen who are
greatly affected of the crisis. It is not the time forpoliticking. It is the time to cooperate, collaborate andcoordinate with our national and local officials to createa strong platform to combat the Covid-19 pandemic. Pay
compassion forward as stressed by Girod (2019).
According to van Wessel, Hilhorst, Schulpen, & Biekart(2019), governments recognize the advocacies of the
CSOs who are capable of organizing relief operations inpartnership with private individuals. This initiative isvery helpful in mobilizing government efforts to initially
respond to peoples’ call for help in times of pandemic
situation.
It is our hope that this force of compassion andcharity indicated the people’s desire and willingness towalk an extra-mile to be able to share their blessings can

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

be the same strong force to challenge the different
oppressive structures that put the poor to the margins ofsociety and to emancipate them from these different
forms of maladies and to restore their human dignity.
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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
Confidentiality of medical data and public
safety and health- Marlon Patrick P. Lofredo, PhD
Institutional Review Board Chair, St. Paul University Quezon
City, Philippines
Professor in Bioethics and Ethics in Hospital Administration,
SPUM Graduate School of Health Sciences, Philippines
Email: mpplofredo@spuqc.edu.phAbstract
The principle of confidentiality and privacy of medical
data is an important patient safeguard, and it is rooted infundamental human rights and ethics principles. The
call for the voluntary waiving of confidentiality andprivacy by COVID+ and suspected patients by involved
healthcare and legal organizations in the Philippines has
put into the debate table its ethical and legal
permissibility. The common rule is confidentiality andprivacy of information is not absolute, and there are laws
delineating specific grounds for its permissible
breaching. The basic ground for breaching is theprimacy of public health and safety over individual rightto privacy. The common good remains the primaryconsideration when conflict between principles occur incases of pandemics like COVDI-19. But care must be
taken to ensure that patients are not discriminated andstigmatized as a result of the breach of confidentiality
and privacy of medical data. The rule of thumb given by
the Philippine National privacy Commission is gather
only what is necessary and disclose only to proper
authorities. Breaching does not mean disclosed data isuniversally accessible. Governments must ensure that
confidentiality remains protected even when such rightis temporarily withheld as demanded by the principles ofrespect for persons, human dignity, autonomy, andjustice.
Introduction
The rapid spread of COVID-19 and the difficulty of
tracing contacts and travel history of patients is creating
a conflict between the principle of confidentiality of
medical data and the demands of public safety andhealth. With the rise of COVID-19 deaths and infection is
the growing number of healthcare professionals getting
infected and dying also. Practically, all are walking blindamidst the pandemic, and other people’s health and wellbeing are also compromised when they go for simple
treatment or check-up but they exhibit similar
symptoms to COVID-19 and are immediately considereda suspect until it turns out negative for SARS-CoV 2
infection.
The reality that some patients lied about their travel
history and contacts further strained the alreadyexhausted healthcare workers, and their communities.
The high-level communicability of COVID-19 and its lackof available specific treatment and vaccine makes it aformidable threat to public safety and health, and one of
the solutions being proposed to curb its fast spread is for
positive and suspected patients to waive confidentialityof their medical data to make tracing easier and toprotect public safety and health. But will this be legal
and ethical?

221

The issue of breaching confidentiality of medical data
in COVID-19 cases was raised in the Philippines by thePhilippine Medical Association (PMA), the Integrated Barof the Philippines (IBP), and the Philippine College ofSurgeons (PCS) when they issued a joint statement
petitioning the COVID 19+ and suspected patients “tovoluntarily waive the confidentiality of their medical
condition and forthrightly inform those they have been
in close contact with; and that the government,
particularly the Department of Health, prudently usesand promptly shares medical information to enable allconcerned authorities, institutions and persons toeffectively take precautionary and remedial measures.”This petition is the result of: the increasing number of
COVID 19+ patients seeking treatment and admission
but are lying about their true condition thereby
compromising not only the health care workers but alsoof the whole health institution’s ability to provide
services; the difficulty of doing timely, adequate andcomplete contact tracing; the increasing number of
unknowing virus carriers who are not tested,
quarantined, isolated, or treated; the demand of fairness
and right to precautionary or remedial measures ofinfected patients; and, the preeminence of the right tosafe and healthy environment over individual right toconfidentiality and privacy (Cepeda 2020; PMA 2020).
In response to the petition, the Philippine InterAgency Task Force, the one managing COVID-19
response in the country, approved on 8 April 2020
Resolution No. 22 directing the Department of Healthand the Office of Civil Defense to enter into a datasharing agreement in accordance with Republic Act No.
10173 or the Data Privacy Act. The Department ofJustice affirmed the validity of the legal and ethical basis
presented by the PMA and the Data privacy Commission
for such action in times of public health emergency. As ofthis writing, COVID 19+ and suspected patients are now
mandated to fully disclose all personal information to
healthcare providers (Ropero 2020), and for healthinstitution to prudently share that information among
themselves to enhance contact tracing.
The principle of confidentiality and privacy of data
The principle of confidentiality is ingrained in the fourpillars of medical ethics: autonomy, justice, beneficence,and nonmaleficence. Particularly, confidentiality andprivacy of information are within the scope of autonomy,
which is the capacity for self-determination. Being
autonomous, however, is not the same as being
respected as an autonomous person. To respect anautonomous person is to acknowledge his/her right tomake choices and to act based on that person’s own
values and belief system.
Respect for autonomy involves not only desistingfrom meddling or intruding with someone’s choices, butsometimes entails providing the person with thenecessary conditions and opportunities for exercisingautonomy. The principle of respect for autonomy implies
that one should be free from coercion in deciding to act,
and that others are obligated to protect confidentiality of
information, respect privacy, and tell the truth.
The principle of respect for autonomy implies that
autonomy has only prima facie standing, that is, it can beoverridden by competing moral considerations. For

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

example, if an individual’s choices endanger publichealth, potentially harm others, or require a scarce
resource, that individual’s autonomy may justifiably be
restricted. Autonomy is limited by the principles of
stewardship, respect for persons, justice and thecommon good. Respect for autonomy, then, should not
be construed as an absolute and foundational value, but
a "middle principle" that requires every individual torespect every other individual’s self-determination to an
appropriate extent within the context of community.
The same reasoning also applies to confidentiality
and privacy of information. Confidentiality guarantees
physician-patient trust and ensures that the patient will
receive the best care from the information he/she
confidently revealed to the healthcare providers, in
effect the healthcare provider becomes the protector of
the patient’s information. The principle prohibits any
health care provider from disclosing any information
about the patient’s condition and other data to others
without prior consent or permission, and if such isprovided, it requires that only authorized access occurs.
Confidentiality and privacy are well protected in law andin hospital procedures and protocols.
Maintaining confidentiality is both a legal and ethicalresponsibility of healthcare professionals. But this is not
an absolute principle – confidentiality can be breachedethically and legally, i.e., when patient confidentiality islikely to put human life at risk of harm, or when thepatient has committed a crime punishable by law, amember of an illegal organization, has a standing
warrant of arrest, and prison escapee, or, his condition
put public safety at risk, like if the patient is sufferingfrom contagious disease, like COVID-19. In such cases,
the healthcare provider must seriously weight he pros
and cons of breaking confidentiality.
The consent requirement of breach of confidentiality
A tricky aspect of breach of confidentiality is consent.
The principle requires that patient must provide freeconsent. But what if the patient refuse to provide
consent? Must consent be taken in all cases of possible
breach of confidentiality?
The American Medical Association (AMA) has theopinion that medical doctors may disclose personal
health information without the specific consent of thepatient (or authorized surrogate when the patient lacks
decision-making capacity) only to the following parties
and reasons:a.other health care personnel for purposes ofproviding care or for health care operations; orb.appropriate authorities when disclosure is requiredby law.
c.other third parties situated to mitigate the threat
when in the physician’s judgment there is a reasonableprobability that the patient will seriously harm
him/herself; or the patient will inflict serious physicalharm on an identifiable individual or individuals.
All other reasons require the consent of the patient(AMA 2016).
The British Medical Association (BMA), on the other
hand, allows breach of confidentiality where the law
permits and “where necessary in a democratic society inthe interests of national security, public safety or the
economic well-being of the country, for the prevention ofdisorder or crime, for the protection of health or morals,
or for the protection of the rights and freedoms ofothers. The effect is similar to that of the common law:
privacy is an important principle which must be
respected but may be breached where other significant
interests prevail. Any such breach must be proportionate
to the benefits/harms it is intended to bring/avoid”(BMA 2020).
The World Medical Association (WMA) has thisstatement on the matter: “The duty of confidentiality
must be paramount except in cases where the physician
is legally or ethically obligated to disclose suchinformation in order to protect the welfare of theindividual patient, third parties or society. In such cases,
the physician must make a reasonable effort to notify thepatient of the obligation to breach confidentiality, andexplain the reasons for doing so, unless this is clearly
inadvisable (such as where telling the patient would
exacerbate a threat). . . In all other cases, confidentiality
may be breached only with the specific consent of thepatient or his/her legal representative or where
necessary for the treatment of the patient, such as inconsultations between medical practitioners” (WMA2016).
The three biggest medical associations all agree that
confidentiality can be breached and that there are cases
where consent may not necessarily be solicited.
Legality of breach of confidentiality in thePhilippines
Although the right to privacy of information is auniversally
guaranteed
humanright,
medicaljurisprudence in the Philippines sees confidentiality of
medical data and details as not absolute. While Civil
Codes and Privacy Act duly protects confidentiality,
certain conditions are identified that warrants
reasonable breach of confidentiality. In particular, theCode of Ethics of the Medical Profession directs that “Thephysician shall hold as private and highly confidential
whatever may be discovered or learned pertinent to thepatient even after death, except when required by law,ordinance or administrative order in the promotion ofjustice, safety and public health. The commitment
extends to discussion with persons acting on a patient’s
behalf. Safeguards shall be applied especially when using
electronic information systems for compiling patientdata, and when dealing with genetic information” (PMA2016). This provision follows the right to privacy
enshrined in Article III, Section 3(1) of the Bill of Rightsof the 1987 Philippine Constitution (Republic of thePhilippines 1987).
The right of the patient to privacy and confidentiality
is well protected in the Magna Carta of Patient’s Rights
and Obligations obliging all those involved in thetreatment of a patient to ensure that the privacy of thepatients is respected and protected in all stages of histreatment. “The patient has the right to demand that all
information, communication and records pertaining to
his care be treated as confidential. Any health careprovider or practitioner involved in the treatment of apatient and all those who have legitimate access to thepatient's record is not authorized to divulge any
information to a third party who has no concern with

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
the care and welfare of the patient without his
consent” (Senate of the Philippines, 2017).
The Magna Carta allows breach of privacy andconfidentiality when: such disclosure will benefit publichealth and safety; when it is in the interest of justice andupon the order of a competent court; when the patients
waives in writing the confidential nature of suchinformation; and, when it is needed for continued
medical treatment or advancement of medical science
subject to de-identification of patient and shared
medical confidentiality for those who have access to theinformation (Senate of the Philippines, 2017).
In 2016, the Health Privacy Code of the Philippines orofficially known as Administrative Order No. 2016-0002
titled ““Privacy Guidelines for the Implementation of thePhilippine Health Information Exchange” waspromulgated. It is a joint administrative order by the
Department of Health (DOH), the Department of Scienceand Technology (DOST) and Philippine Health Insurance
Corporation (Philhealth) to promote informationexchange in health care service while also protection andpromoting the right to privacy of data subjects in ahealthcare setup. On the Use and Disclosure of Health
Information, Rule III-1 of the Code allows the use anddisclosure of health information subject to thelimitations covered by the consent given by the patient,or his or her authorized representative, and shall only be
for the following purposes “. . . reporting ofcommunicable, infectious and other notifiable diseases,
including those that pose a serious health and safety
threat to the public such as, but not limited to . . .
Breakthrough epidemic of contagious disease.” The
Code (Rule III-1.3) also mandates that: “… in case of
emergency, where time is of the essence, disclosure may
be made even without court order.” Confidentiality canbe lifted “…b) when the public health and safety sodemand; or c) when the patient waives this right.”
In 2018, Republic Act No. 11332, An Act Providing
Policies and Prescribing Procedures on Surveillance andResponse to Notifiable Diseases, Epidemics, and Health
Events of Public Health Concern, and Appropriating
Funds Therefor, was enacted which required mandatory
reporting of notifiable diseases and health events ofpublic concern. Section 6g of the law enjoins all those
involved in conducting disease surveillance andresponse activities to respect, to the fullest extent
possible, the rights of people to liberty, bodily integrity,and privacy without prejudice to public health andsecurity, and Section 9e warns the public that “noncooperation” of the person or entities identified ashaving the notifiable disease, or affected by the health
event of public concern is illegal.
Apprehensions on breaching confidentiality andprivacy of medical data arose in the country as a result of
the enactment of the Data Privacy Act in 2012 (DPA)
which laid strict requirements designed to protect
personal information in both government and private
sector organizations. Section 13 of the said law, allows
the processing (understood in the Act as any operationor any set of operations performed upon personal
information including, but not limited to, the collection,
recording,organization,
storage,updatingormodification, retrieval, consultation, use, consolidation,
blocking, erasure or destruction of data) of sensitive223

personal information and privileged information when:
the data subject has given his or her consent; it isnecessary to protect the life and health of the data
subject or another person, and the data subject is notlegally or physically able to express his or her consent
prior to the processing; the processing is necessary for
purposes of medical treatment, is carried out by a
medical practitioner or a medical treatment institution,
and an adequate level of protection of personal
information is ensured.
The DPA still require the consent of the person before
any disclosure or breach of confidentiality can happen.
Previous laws and directives exclude conditions likedanger to public safety and health from the requirementof consent. When this issue was referred to the National
Privacy Commission (NPC) in light of the COVID 19
pandemic, it released Bulletin No. 3, on data protection
in times of emergency, dated March 19, 2020, clarifyingthat “during this time, it is not only the ‘misuse’ of datathat concerns us but also the ‘missed’ use that could havemade a difference in containing the disease” and advisedthat the law allows the collection of what is necessary
but disclosure must only be to the proper authority. The
NPC further clarified that: “Data protection and privacy
should not hinder the government from collecting, using,and sharing personal information during this time of
public health emergency. Neither does the law limit
public health authorities from using available technology
and databases to stop the spread of the virus. The
principles contained in the law allow the use of data totreat patients, prevent imminent threats, and protect thecountry’s public health and still provide the level ofprotection the citizens expect. The Data Privacy Act of2012 is an enabler in critical times like this.”
Again, the NPC released Bulletin No. 7 on 6 April
2020, containing its official statement on calls forpatients to waive privacy rights and publicly disclose
health status. The NPC reiterated that the Data Privacy
Act of 2012 is not a hindrance to the COVID 19 response.
The NPC also clarified that Bulletin No. 3 was not meant“to support any request for the voluntary waiver by
COVID-19 patients, PUIs (persons under investigation)
and PUMs (persons under monitoring) of theconfidentiality of their medical condition” but was
released in connection with the Commission’s appeal forthe release only of “trusted and verified information,”
especially during an “unfamiliar global pandemic.”
In response to the appeal of the PMA, IBP and PCS,
the Commission provided the following guidelines:
On sharing with other authorized public authorities, theDOH may do so subject to the limitations that the sharing
is (a) pursuant to a public function or a public service,(b) based on the constitutional or statutory mandate of
the DOH and/or the other public authorities, (c) strictly
following set protocols and processes, (d) ensuring thesecurity of such shared information, and (e) upholding
data subjects’ rights.
With respect to sharing medical information ofindividuals to private health institutions, the Healthdepartment would be in the best position to determine if
such is consistent with the provisions of RA 11332 andother applicable protocols in a pandemic.
On the call for patients, PUIs and PUMs to share orconsent to the sharing of personal data to the general

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

public for contact tracing, we affirm our stand that doing
so may not be as helpful to contact tracing interventions
as this can only induce fear among these individuals
given the multiple reports now on physical assaults,
harassments, and discrimination endured by patients,
PUIs, PUMs, and even health workers. These threats totheir safety and security may discourage them to reporttheir symptoms to public authorities, take confirmatory
tests, and submit to treatments.
If a patient, PUI, or PUM himself or herself would
want to disclose such information, as what some public
figures have done, that is their personal choice.
On seeking consent, the DPA requires consent to be
freely given, specific, and an informed indication of willthat they indeed agree to the public disclosure. Informed
consent requires that these patients, PUIs, or PUMs havebeen made aware of the risks that may arise from thedisclosure, including the risk of being subjected toviolent physical attacks as some COVID positive patientsand their family members have experienced according tonews reports.
Although the legality of propriety of breach ofconfidentiality and privacy has been clarified by the NPC,
it still reiterated that ‘even in times of calamity or a stateof a public health emergency, rules on patient privacy,
the confidentiality of health records, medical ethics, anddata subjects’ rights remain in effect and upholding themequate to protecting lives.” This is why the NPC firmly
advised that collect only what is necessary, disclose only
to proper authority.
There is then a common permission in Philippine law
for the reasonable, ethical, and legal breach ofconfidentiality and privacy of medical data, especially intimes of national health emergency, such as COVID 19
pandemic, and for the protection of public health andsafety. But such disclosure are not meant for public
consumption. There are strict requirements as to who
and to whom such disclosure can be made, and consent
must be freely given by the patient before any disclosure
is made, except when greater public safety and healthrequires it, or such right to consent is waived personallyby the patient, or by lawful order from court.
The primacy of common good over individual goodor right
Confidentiality and privacy of information is closely tiedwith the ethics principles of respect for human dignity,
respect for persons, autonomy, justice, common good,
double effect, nonmaleficence, and beneficence.
Consequently, the principle is also checked and balancedby the same concomitant principles. The principle ofcommon good serves as a regulating principle for
confidentiality and privacy.
In general, the common good “consists of all theconditions of society and the goods secured by thoseconditions, which allow individuals to achieve humanand spiritual flourishing” (O’Rourke and Boyle 2011, 19).
It requires that all people and governments must be
actively concerned in promoting the health and welfareof everyone so that each can contribute to the common
good of all. It has three essential elements: respect for
persons, social welfare, and peace and security. In so far
as the common good assumes respect for persons, it
compels public authorities to respect the fundamental

human rights of each person. Insofar as it assumes social
welfare, the common good requires that the
infrastructure of society is favorable to the social wellbeing and development of its members.
The concept of the primacy of common good overindividual goods is prevalent in Thomistic philosophy,
inspired by the Aristotelian maxim that the good of thewhole is more divine than the good of the parts. Jacques
Maritain, following Thomas Aquinas’s line of thinking,explains that “because the common good is the humancommon good, it includes within its essence, as we shallsee later, the service of the human person” (Maritain
1946, 421). It has long been held in Christian philosophy
that the person is a totality in itself, that person is a partof a greater whole. While common good serves thetotality of the human person, “the person still remains, as
an individual or part, inferior and subordinated to thewhole and must, as an organ of the whole, serve thecommon work” (Maritain 1946, 446). It must be
understood from these suppositions that the individual
must serve the common good since the common good, by
its very nature, serves the individual in its totality.
Working for the common good is “equally to everyone’s
advantage” (Rawls 1972).
But Maritain also argued that the common good is not
simply a collection of private goods nor a good of awhole which sacrifices its parts. “It is common to thewhole and to the parts and requires recognition of thefundamental rights of persons. To achieve the common
good society needs a significant contribution fromindividuals” (Benestad 1983). While individual rights
are respected, the individual must in turn make asignificant contribution to the common good, or elsesuch right may not be appropriately respected in thecontext of the community. This is to avoid thecommunist and totalitarian interpretation that
individual rights can be duly sacrificed permanently andwhimsically for the common good. We must be quick toremember that the principle of common good does not
advocate the permanent surrender or sacrifice ofindividual rights, but rather the temporary suspension ofsuch rights in such conditions that may endanger thegood of the whole. Once risky and dangerous conditions
passed, then all rights are restored. Again, the context ofthe such prioritizing of common good over individual
good must be considered seriously, since the danger ofabuse is always lurking in the dark crevices of
uncertainty and knowledge gaps.
The observation of Robert J. Samuelson in his 1992
Newsweek article is still challenging each and every oneof us today amidst the COVID 19 pandemic: “We face achoice between a society where people accept modest
sacrifices for a common good or a more contentious
society where groups selfishly protect their own
benefits.” Such observation is apparent in everyday
news showing people disregarding policies and rules onsocial distancing and quarrelling with quarantine
enforcers insisting on their rights and privileges over
and above the community’s good. Temporarily limiting
the exercise of our right to free movement, right toengage in business and livelihood, and right toconfidentiality and privacy are significant contributions
to the common good in time of pandemic.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
Moreover, common good makes democracy work
since every citizen is expected to contribute something
towards the common good and not just maximizing
personal benefit. Political philosophies like those of
Plato, Socrates, John Locke, John Rawls, Niccolo
Machiavelli, David Hume, and Jean-Jacques Rousseau,
believed that democracy will fall if people become moreconcerned with personal gains at the expense of thecommon good. In such condition, social cohesion andunity among citizens suffers, to the detriment of all. But
despite the myriads of definitions of common good,“philosophers and other social scientists agree that when
citizens no longer care about the common good and nolonger take responsibility for ensuring a good life for all
citizens, then the democracy at best becomes
dysfunctional and at worse fails by transitioning into
dictatorship or chaos” (Johnson 2018). Limiting theexercise of some of our rights may actually help inpreserving a country’s democracy and for the proper
functioning of our democratic systems during
pandemics.
The dangers and effects of pandemic cannot be
underestimated. It is not merely a health problem, but it
also alters the way social structures and politicalsystems operates. It necessitates change in lifestyle andparadigm and the way we see our rights and privileges.
If we do not let go of our entitlements and voluntarily or
willingly limit the exercise of some of our precious
rights, then we may end up sharing a common fate –infection and worse, death and the utter failure of socialand political structures and systems. Allowing breach ofconfidentiality and privacy of medical data in time ofpandemic is for the common good, and that common
good is public safety and health. Again, common good
does not altogether nullify individual rights, in fact, inthe long run, it may guarantee greater enjoyment of
those rights after the pandemic.
The problem of Discrimination and Stigmatization
The disclosure of medical data of COVID-19+ andsuspected patients may lead to discrimination andstigmatization. These are the primary reasons why somegroups and policy makers are not amenable to breaching
confidentiality and privacy for the sake of public safety
and health. The requirement for prior consent is not
only in compliance with the demands of the principles ofrespect of person and human dignity, autonomy andjustice, but also a personal shield of the patient against
unsolicited and unnecessary prying into his/her medical
data. Due to the high degree of communicability of
SARS-CoV 2 which causes COVID-19, the patients and his
relatives and friends, especially those whom he/she had
contact prior to testing positive of the disease, are at
great risk of discrimination and stigmatization.
We have already seen people denying entry to
COVID-19 suspected or positive individuals to theirvillages, and even when they are already declared curedof the disease, the stigma remains, and they are still
avoided by others. The Universal Declaration on
Bioethics and Human Rights, Article 11 provides that:“No individual or group should be discriminated againstor stigmatized on any grounds in violation of humandignity, human rights and fundamental freedoms”(UNESCO, 2005).

225

The NPC is very clear in its directive to healthcare
professionals that they only gather that which arenecessary and disclose only to proper authorities. Thismeans that data disclosed are not for public
consumption, but primarily meant to hasten tracing,
identification, quarantine, isolation, and treatment of
COVID-19 patients, and to protect the healthcare
professionals as well.
Should village officials be
informed of the medical data of the members of theircommunity found or suspected to have the virus? Yes,
since this will help healthcare workers identify those towhom the patient had contact with, but care should betaken that other members of the community do not haveaccess to the information.
Although leakage of information is difficult toprevent, the DOH must promulgate guidelines that
include protection of COVDI-19 patients against
discrimination and stigmatization. This may include
community-based health education and mass media andonline information campaigns.
Conclusion
While confidentiality and privacy of medical data issacred in medical ethics, it is not an absolute principle.
For the sake of common good, that is, public health andsafety, this can be breached and disclosure or necessary
data among healthcare providers and proper authorities
is permissible ethically and legally. Some rights can belimited temporarily for the sake of greater good, andevery act for the common good ultimately benefits eventhe person who willingly surrendered provisionallysome rights. These are trying times and COVID-19 ischanging our way of behaving, lifestyle, and shifting ourparadigms. All must adjust to the new normal for thesake of the common good without compromisingpermanently individual rights. Government must ensurethat confidentiality is still protected while taking allmeans to identify those who may have the virus. In thisway those COVID-19 patients will be well protectedagainst discrimination and stigmatization.
References

AMA (2016) Opinions on Privacy, Confidentiality & Medical
Records.
At:
https://www.ama-assn.org/sites/amaassn.org/files/corp/media-browser/code-of-medicalethics-chapter-3.pdf (Accessed 15 April 2020).
BMA (2020) Confidentiality and health records toolkit. At:
https://www.bma.org.uk/media/1846/bmaconfidentiality-and-health-records-toolkit.pdf (Accessed 14
April 2020).
BMA (2016) WMA Statement on Patient Advocacy andConfidentiality. At: https://www.wma.net/policies-post/
wma-statement-on-patient-advocacy-and-confidentiality/(Accessed 15 April 2020).
Benestad JB (1983) Rights, Virtue, and the Common Good. At:
https://www.crisismagazine.com/1983/rights-virtue-andthe-common-good (Accessed 13 April 2020).
Cepeda M (2020) Coronavirus patients urged to waive
confidentiality: ‘Being diagnosed not a crime, stigma’. At:
https://www.rappler.com/nation/257036-coronaviruspatients-urged-waive-confidentiality-being-diagnosed-notcrime-stigma (Accessed 10 April 2020).
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Philippine Health Insurance Corporation (2016) HealthPrivacy Code Specifying the Joint A.O. No. 2016-0002,“Privacy Guidelines for the Implementation of the226

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Philippine
HealthInformation
Exchange.”At:
http://ehealth.doh.gov.ph/images/HealthPrivacyCode.pdf(Accessed 13 April 2020).
Johnson DW (2018) Democracy Depends On Promoting The
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us/blog/constructive-controversy/201802/democracydepends-promoting-the-common-good (Accessed 12 April2020).
Maritain J (1946). The Person and the Common Good. In The
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authority. At: https://www.privacy.gov.ph/2020/03/npcphe-bulletin-no-3-collect-what-is-necessary-disclose-onlyto-the-proper-authority/ (Accessed 12 April 2020).
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12 April 2020).
O’Rourke KD and Boyle PJ (2011) Medical Ethics: Sources of
Catholic Teachings, 4th ed. Washington DC: Georgetown
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Mobile contact tracing technology: way out
or lock up?
- Maria Patrão Neves, PhD
Professor, Universidade dos Açores, Ponta Delgada, Portugal
Email: m.patrao.neves@gmail.com
www.mpatraoneves.pt

Abstract
Our present time is characterized by three crises: thehealth crisis that caused an economic crisis anddegenerated into a social crisis. While biomedical
technologies are not able to provide safe and efficient
treatment or a vaccine, digital technologies stepped inproposing a fine-tuned mobile contact tracing to mitigate
the pandemic effects. It was first used in Asia, and then
expanded, following different models in the different
countries, with regard both to technological systems andvalue systems. The first experiences tended to set up aneffective system for the pursued objectives, seeking toadjust to the ethical concerns of the community; therecent European initiative starts by identifying the
ethical requirements to be protected, and to which thedigital system of contact tracing must respond.
The European Recommendation (8/4/2020) for a
Pan-European Privacy-Preserving Proximity Tracing(PePP-PT), requires full compliance with the Charter ofFundamental Rights of the Union, and the technologicaloption is shaped to acknowledge an opting-in system,
the sole use of anonymized and aggregated data, andforeseeing expiration measures and deletion of person’sdata. Still, the Recommendation also acknowledges theeventual and temporary need to restrain thefundamental rights in the light of public interest, evenbeyond the crisis, pending adequate justification, thus
establishing a quite permissive framework for possible
action. De-confinement, or ‘way out’, is not for free:circulation will be as broad and free as extensive andprecise the tracking of people in their interactions might
be. The 'way out', will always imply a loss of rights, notalways consented, for a time that can drag on.
Meanwhile, the history of humanity shows that the social
experiences have no return, therefore, it may always leadto a new form of 'lock up'.
Introduction
The present moment is characterized by 3 crises ofenormous proportions. The first is the health crisis thatbroke out at the end of 2019, in China, and which,meanwhile, spread to the whole world, having
determined the already very serious economic crisis
which, in turn, is leading now to an evident social crisis
which, like previous ones, threatens to be of
unprecedented dimension for this generation.
The current health crisis can only be effectively andtotally overcome with the production of a safe andefficient vaccine, which, despite frequent misleading
information or advertising (by scientists seeking fame,by research centers seeking funding, and by countries
seeking prestige) will not be possible to achieve in the
coming long months. As such, national health authorities
and governments in general were left with one single
effective means of combating the epidemic: social

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
isolation, with leads to economic breakdown and social
collapse.
In this context, all governments are trying to find thebest solutions to mitigate the current state of ageneralized crisis, aiming immediately not at the causes,
but at the effects, that is, not acting directly on the healthcrisis (for lack of effective tools), but on economics and,
consequently, on the social crisis.
Therefore, while biotechnologies fail to produce thenecessary and desired responses – vaccines and drugs
that are safe and effective –, digital technologies advancewith some proposals, among which the mobile orsmartphone contact tracing stands out, considered themost effective scientific-technological response, but also
the most controversial ethically.
1. Mobile contact tracing: the first experiences
Contact tracing for contagious diseases is not a new andoriginal idea of our times to control the spread of SARSCoV-2. In ancient times, lepers were obliged to use a bell
strapped to their ankles so that their presence could beannounced at a distance, allowing others to stay awayfrom any contact and thus reducing the risk of infection.
In our time, when a person is diagnosed with aninfectious disease, the physician and the health services
in general try to identify all persons with whom thepatient has been in contact and who may have become
infected. The sooner all contacts are identified, forclinical evaluation, treatment and prevention, the more
effectively the spread of the infectious diseases to family
members, friends and acquaintances is controlled. It is
obvious that this process depends heavily on thepatient's recollections, depending also from numerous
other variables that make it more or less time consuming
and affecting its level of effectiveness. The novelty at thepresent time is the way used to implement an old idea:
the application of digital technology to contact tracing
for infectious diseases control, and specifically to SARSCoV-2.
Digital technology has been used for the last past
years to identify, locate and follow people, in different
situations, and for different reasons, mostly within legal
investigations and political reasons. It has also been usedwithin healthcare, mostly to transmit clinical data ofpatients under monitoring to their doctors. But its
application to infectious diseases, to identify and trace
citizens, is more recent6. It was in 2014, during the last
Ebola outbreak that digital technology was used andconsidered very successful in containing EVD
transmission. Mobile contact tracing was thenparticularly used in urban Nigeria, due to robust
surveillance systems and leveraging mobile applications
for real-time monitoring (Swanson et al., 2018), and theWorld Health Organization (2014) presented it as “anintegral component of the overall strategy for controlling
an outbreak of Ebola virus disease (EVD)”, and as “animportant part of epidemiologic investigation and active
surveillance”
The application of digital technology to infectious
diseases, exceeds the strict and exclusive domain of thepatient-physician relationship, to which was restricted,
6 In 2011, Cambridge University proposed an app for the flu(the FluPhone), but the adoption rate was below 1%.

227

to begin involving a whole community and different
authorities, which is even more true when considering ahighly infectious disease such as SARS-CoV-2. In
situations of epidemic outbreaks, the priority for action
has always been public health, without a simultaneousconsideration of other ethical concerns besides theprotection of people's health and life. Issues such as
medical confidentiality or citizens' privacy have been
overlooked in the face of an emergency.
Today, however, in the current pandemic situation,
and with the possibility of successive waves of infectious
outbreaks, we find ourselves in an extended time framein which, if it is true that health protection gains evenmore importance, ethical issues related to the integrityof procedures in respect of individual rights cannot
remain suspended. Both concerns should apply to when
considering digital contact tracing.
Asian experiences
Digital contact tracing, tuned as a strategy to fightCorona virus infection, started to be used in Asia, in
China, and then also in South Korea and Singapore,
following different models in these different countries(Huang et al., 2020).
China was the first country to implement a digitalcontact tracing as a strategy to control Corona virus
infection. The country created the app Health Code, to be
downloaded in all mobile phones, which gives users acolour-code (green, yellow and red) according to a
combination of factors, namely their health status, travel
history, and if they have been in contact with someone
infected. Citizens access to public transportation, butalso to shops, restaurants and other establishments
depends on the color they receive from the authorities,
green allowing access to all public spaces, and red
requiring home confinement. It also provides the user
with a OR code that can be scanned by authorities.
Health Code was developed and it is managed by thegovernment and runs in different platforms. It is notclear how the app works, which data are being stored,
and for what purposes they can be used both, in thepresent and in the future.
South Korea, benefiting from its past experience with
the Middle East Respiratory Syndrome (MERS) outbreakin 2015, namely the establishment of a legal basis forassessing citizen’s information, was able to swiftly
develop a robust contact tracing for the present
pandemic. The Covid-19 Smart Management System(SMS) uses data from 28 organizations (national entities,
smartphone companies, and credit companies, thus
using GPS phone tracking, credit-card records, andsurveillance camera footage) under the exclusive
management of Centers for Disease Control andPrevention (KCDC), and follows the movement of all
infected individuals, relying in massive testing of the
population. Anonymised data showing Covid-19
patient's movements is published online. Those whocome in contact with infected persons are tested again: if
they test positive, they are hospitalized; if not, theyshould remain in quarantine for 14 days. Information
gathered under this system is only accessible toepidemic investigators from KCDC, being purged from all
personal information. This system is consideredtransparent and South Koreans have generally installed.

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Nevertheless, there has been many complaints about thepersonal nature of the data made public by authorities,
which can include age and gender, and also businesses
visited or hotels and toilets visited.
Singapore developed the app TraceTogether 7 , acommunity-driven contact. Participating devices
exchange proximity and duration of an encounter
information whenever an app detects another device
with the TraceTogether installed, using the Bluetooth
Relative Signal Strength Indicator (RSSI) between nearby
phones. Bluetooth signals are less intrusive than themobile software applications. This system has been
considered a paradigm for other countries: the download
is voluntary; data (about interaction with otherTraceTogether users) are stored in one’s phone for 21days, being then deleted; location data are not collected;
if a TraceTogether user is tested positive for Covid-19, isrequired by law to work together with the Ministry of
Health to trace all the patient’s contacts for the past 14
days. By middle April, new cases began to grow rapidly
in Singapore (mostly in migrant worker’s dormitories),
and the government immediately started to develop new
apps, in addition to Trace Together, to overcome thelimitations of different smartphone systems (android,
IOS).
Other national experiences
The number of countries that are implementing digitalcontact tracing is increasing, also as the economic
pressure to end the lockdown increases. Many countries,
outside Asia, are currently planning strategies toimplement it, taking into account the diversity ofsystems already in place. In fact, there are many otherexamples besides Asian ones.
Israeli created the app HaMagen, Hebrew for 'theshield', to identify and track people infected with COVID19 also during their quarantine. It was developed using
open-source tools. Therefore, it can be easily installed inother countries, at no cost, what is raising the interest of
several countries looking for a quick and already tested
solution.
Iran created the app AC19, to be installed by all
Iranians before going to a hospital or health center. It is
supposed to be a diagnosis app, capable to do the user’s
diagnose by asking a series of yes and no questions, atthe same time that it locates them in real time.
These first experiences on mobile contact tracing
show that it is generally considered effective to control
the spread of an infection, such as the Coronavirus,
insofar: population is widely tested; citizens have amobile phone; and they are compelled (forcibly) or
accept (voluntarily) the national tracing system.
These first experiences also show that, in a shortperiod of time, many countries started using mobile
contact tracing, considering it the most successful way tocontrol the health crisis and to mitigate the economic
and social crises. Although accurate information toquantify its effectiveness is not yet available, their use bysome countries raised the eagerness of others to take thesame step.
Thirdly, these first experiences show that digitalcontact tracing can be designed and implemented in
7 https://tracetogether.zendesk.com/hc/en-sg

many different ways, with regard to technologicalsystems and value systems. Regarding the latter, thesystems can be more or less transparent in terms ofprocedures and more or less respectful of individual
rights and of citizens' privacy. Overall, and while someethical concerns are notorious, the value of public healthand collective security clearly prevailed in these firstexperiences, other major ethical values fading away. It
can be considered that beyond the case of authoritative
governments, there were some factors that enhanced thewillingness of the Asian population (as well as the
Israeli), to accept and collaborate with digital contact
tracing such as: former experiences dealing withepidemic outbreaks (in Asia); living in highly
technologically advanced societies and countries (hightech societies); nurturing a strong feeling of communityand discipline.
Briefly, we can conclude that the effectiveness ofmobile contact tracing does not depend only ontechnological progress, but also on the social, political,
cultural and moral context in which it is implemented.
For this reason, the adoption of mobile contact tracing in
the European Union necessarily involves specificquestions, more of an ethical than of a technical nature,and those of a technical nature derive from the need toanswer the ethical questions.
2. Mobile contact-tracing: the European initiative
The European Union formally joined countries in favor of
adopting digital contact tracing on 8 April, when theEuropean Commission presented its Recommendation C(2020) 2296 to Member States “on a common Union
toolbox for the use of technology and data to combat andexit from the COVID-19 crisis, in particular concerning
mobile applications and the use of anonymised mobility
data”.
The general objective is to develop “a common
approach to the use of digital technologies and data in
response to the current crisis” that overcomes thelimitations and weaknesses of national, fragmented(closed groups or workplace contacts) anduncoordinated options, also preventing the “proliferationof applications that are not compatible with the Unionlaw”8. This pan-European approach for the use of mobile
applications, together with a common scheme for using
anonymized and aggregated data, should leverage theeffectiveness of the system due to the greater amount of
accurate data and extensive collaboration, both
important to better predict the evolution and spread of
the infection (“in providing information on the level ofvirus circulation, in assessing the effectiveness of physicaldistancing and confinement measures, and in informing
de-escalation strategies”), as well as sustaining the
integrity of the Single Market.
In this Recommendation, the European Commission
urged Member States to develop a COVID-19 mobile
application by 15 April 2020, to be urgently adopted,
working together with the Commission, and theEuropean Data Protection supervisor. By 31 May,
Member States should report to the Commission the

8 European Commission, Recommendation, “Has adopted thisrecommendation”, 13(2).

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
actions taken, pursuant this Recommendation. A
potential pan-European application is not yet excluded.
Despite the very short period of time established todevelop a European mobile contact tracing system, theEuropean Union did not import technical solutions
already implemented in other countries. Certainly
benefiting from the knowledge of the existing systems,
the European Commission's major concern was to
identify the ethical concerns to be taken into accountwhen designing the European system, especially in viewof its socio-cultural context. The European Union's spaceis characterized by a strong democratic experience and abroad and rigorous implementation of human rights,
from which a demanding awareness of the fundamental
rights, freedoms and guarantees of all European citizens
has developed. It is also in this context that the European
Union has a General Data Protection Regulation (EUGDPR, 2016/679), in force since 2018, and which
presents the most demanding legal framework in theworld in terms of data protection.
Ethical concerns
The European Commission's Recommendation is clear
and unambiguous in its demand for full compliance with
the Charter of Fundamental Rights of the European
Union (2000), with regard to individual rights andfreedoms, with particular emphasis on the rights to
privacy and protection of personal data. It also refers to:transparency of the procedures, especially on the dataprocessed and the people involved; prevention ofsurveillance and stigmatization; clear and regularcomprehensive communication to the public, also
providing opportunities for the public to interact andparticipate in discussions.
Notwithstandingthesesafeguards,
theRecommendation also includes some statements that goin the opposite direction, by admitting restrictions to thehigh ethical standards that the European citizens enjoy
under the public interest. So, when the public interest is
at stake, and “in particular for monitoring and alert
purposes, the prevention or control of communicablediseases and other serious threats to health” (European
Commission 2020; “Whereas”, 7) data may be processedinter alia without explicit consent. Besides, Member
States are allowed “to adopt legislative measures torestrict the scope of certain rights and obligations
established […] when such restrictions constitute anecessary, appropriate and proportionate measure withina democratic society to achieve certain objectives.”(European Commission 2020; “Whereas”, 10).
In fact, the European Commission recognizes that“given the functions of smartphones applications […], theiruse is capable of affecting the exercise of certain
fundamental rights such as inter alia the right to respects
for privacy and family life”9, admitting that Member
States' laws may have to set out or permit limitations to
the exercise of certain fundamental rights, althoughthese restrictions “must be justified and proportioned.”(“Whereas”, 23). Of particular concern is the statement that“any such restrictions should, in particular, be
temporary, in that they remain strictly limited to what isnecessary to combat the crisis and do not continue to9 European Commission, Recommendation, “Whereas”, 17.

229

exist, without an adequate justification, after the crisis
has passed.” (European Commission, Recommendation,“Whereas”, 23)
The acceptance of possible restrictions on
fundamental rights when necessary, in the light of the
public interest, and which can be extend beyond thecrisis, through adequate justification, ultimately
establishes a quite permissive framework for possible
action by the authorities.
Technical solution
The European initiative is being designed to address the
ethical concerns of its citizens. In this sense, we can saythat there is an inversion of priorities in relation to thefirst experiences of contact tracing: instead of setting up
an effective system for the pursued objectives, whichseeks to adjust as far as possible to the ethical concernsof the community, the European Commission first
identifies the ethical requirements to be protected towhich the digital system of contact tracing must respond.
It is in this context that the European technologicaloption, The Pan-European Privacy-Preserving Proximity
Tracing (PePP-PT), moves away from systems that rely
on GPS, preferring less intrusive technologies, such as
Bluetooth Low Energy based systems that do not collectpersonally identifiable information or user location data,with the list of contacts remaining on the user's device,and that require explicit user’s consent. Still, theCommission's requirements for a mobile contact tracing
system are tougher, more stringent, with specifications
at various levels referring to- nature: voluntary (opting-in system)- data collected: anonymization of identity andconfidentiality of communications(16(1)); avoidance ofprocessing data on location movements, but setting acommon approach for the use of anonymized andaggregated mobility data if these became necessary (formodelling of the virus spreads, and of the economic
effects of the crisis); the solely use of anonymized andaggregated data where possible; data on the infected
personremains
anonymous;
preventing
deanonymization and avoid re-identification (20(3));
immediate and irreversible deletion of all accidentallyprocessed data capable of identifying individuals (20(4))- data storage/access: on the mobile device, withpossible access by health authorities and data storage(16(3))- data processing: anonymized and aggregated where
possible (16(2))- data deletion: expiration measures and deletion of aperson’s data in principle after a period of 90 days or, atthe latest, when the pandemic is declared under control(16(5), 20(5).)
The effectiveness of this system will depend heavily
on a necessary parallel action of wider testing and also
on the acceptance and collaboration of the generalpublic, which will only be achieved if the system isreliable. In any case, it will leave out elderly citizens, andalso the most disadvantaged, such as the homeless, who
do not have a cell phone.
Meanwhile, the required general trust is alreadybeginning to deteriorate, namely with the recent lack oftransparency in the software operations, after having
verified that the responsible consortium changed the230

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

option of using a decentralized protocol in thetechnology, considered as having higher privacy
protections, for a centralized data storage, which can beprone to less security standards. Following thisoccurrence, some members of the consortium withdrew
from the project, and about 300 academics, from morethan 25 countries, published an open letter10, urging
governments to distance themselves from theapplication of contact tracing software that stores data
centrally.
Way out or lock up?
Digital contact tracing appears initially as a key to deconfinement and, in this sense, as an instrument to
mitigate the economic and social crisis, that is, acting
more on the effects than on the causes of the healthcrisis. After all, with regard to health, de-confinement will
increase the number of infections, previously estimatedto be acceptable according to the capacity of admissionsof health services. Nevertheless, the Pan-European
approach also foresees monitoring the evolution of theinfection and predicting the diffusion of the disease andthe impact on needs in the health systems, thus also
acting, in the medium term, directly at the healthcare
level.
The way out of the coronavirus lockdown, to deconfinement, made possible by digital technologies, isnot, however, for free: circulation will be as broad andfree as extensive and precise the tracking of people intheir interactions might be. Despite the demanding
ethical concerns, the 'way out' will always imply a loss ofrights, not always consented, for a time that can drag on.
We exchange personal privacy and freedom for socialand economic sustainability.
Meanwhile, the history of humanity, shows that thesocial experiences have no return, therefore, it may
always lead to a new form of 'lock up'.
Once the mobile contact tracing system is set up, it
will remain available, because it will certainly be useful,for other reasons, for other purposes that may also be
justified in terms of public interest. The fundamental
ethical question, to which each and all of us ought toanswer, is to what extent do we want to sacrifice ourpersonal sphere, in which human identity was generated
and nurtured, to the public space, in which we fulfill
ourselves as persons.
References

European Commission, Recommendation on a common Union
toolbox for the use of technology and data to combat and exitfrom the COVID-19 crisis, in particular concerning mobile
applications and the use of anonymised mobility data,
8/4/2020, C(2020) 2296 final: http://data.europa.eu/
eli/reco/2020/518/oj
European Union, Charter of Fundamental Rights of the Union(2000/C 364/01), Official Journal of the European
Communities, 18/12/2000: https://eur-lex.europa.eu/
legal-content/EN/TXT/?uri=CELEX%3A12012P%2FTXT
European Union, Regulation (EU) 2016/679 of the European
Parliament and of the Council of 27 April 2016 on theprotection of natural persons with regard to the processingof personal data and on the free movement of such data,
and repealing Directive 95/46/EC (General Data Protection
10 https://main.sec.uni-hannover.de/JointStatement.pdf

Regulation) (EU GDPR, 2016/679), Official Journal of theEuropeanCommunities,
4/5/2016:
https://eurlex.europa.eu/eli/reg/2016/679/oj
Yasheng Huang, Meicen Sun, Yuze Sui, “How Digital Contact
Tracing Slowed Covid-19 in East Asia”, Harvard Business
Review, April 15, 2020.
Swanson, Krista C. et al., “Contact tracing performance during
the Ebola epidemic in Liberia, 2014-2015”, PloS Negl Trop
Dis., 2018 Sep., 12(9).
World Health Organization (WHO), “Disease Surveillance andResponse Programme Area Disease Prevention and Control
Cluster”,
2014:
https://www.who.int/csr/resources/
publications/ebola/contact-tracing-during-outbreak-ofebola.pdf.

The application of artificial intelligence tothe medical field: report of a qualitative
investigation-Taketoshi Okita
Department of Medical Ethics, Tohoku University Graduate
School of Medicine, Sendai, Miyagi, Japan
Email: okita@med.tohoku.ac.jp-Atsushi Asai
Department of Medical Ethics, Tohoku University Graduate
School of Medicine, Sendai, Miyagi, Japan-Tsuyoshi Horie
Department of Clinical Philosophy, Osaka University Graduate
School of Letters, Toyonaka, Osaka, Japan-Seiji Bito
Division of Clinical Epidemiology, National Tokyo Medical
Center, National Hospital Organization, Tokyo, Japan

Abstract
Progress in artificial intelligence (AI) technologicalinnovation raises questions about the role of medical
staff and the meaning of medical specialization. This
study involved a qualitative survey of medical
professionals and ordinary citizens to expand knowledgeof this topic. A combination of Neo-Socratic Dialogue(NSD) and Transfer Dialogue (TD) techniques, was used
to acquire knowledge related to emerging forms of
medical care and changing work demands after the
implementation of AI, qualitatively analyzing the TD
transcript only. Eleven subjects participated in two
surveys (13–14 January, 2018 and 11–12 August, 2018).
The main points raised during TD were classified into
five categories: i) Functions which AI could
perform/would find difficult to perform, ii) Changes inmedicine caused by AI, iii) Necessary preparations forthe application of AI to medicine, iv) Concerns about AI,
and v) Others. The survey findings suggest that
initiatives to promote the acceptance of each individualin society and appropriate technological development
are essential to the process of preparing for the changes
in medicine following the implementation of AI. These
preparatory conditions cannot be limited to medical
professionals, and must extend to workers across all
disciplines and to society as a whole.
Introduction
In recent years, artificial intelligence (AI) innovation has
proceeded at a dizzying pace, and its application to
medicine is being promoted on a global scale. In relation
to assessments and operations previously conducted byEubios Journal of Asian and International Bioethics 30(5) (June 2020)
doctors and other medical professionals only—such as
diagnosis of diseases such as cancer, the selection oftreatment, and surgical intervention—the developmentof AI has allowed for support in these areas;
furthermore, a significant portion of procedures can be
conducted independently by AI.
In addition, as AI technological innovation progresses,
questions concerning the role of medical staff and themeaning of medical specialization have been raised. The
clarification of the qualitative changes that AI will bringto medicine and the work of medical professionals is anurgent task that needs addressing before AI can be fullyand effectively integrated into the medical field.
This study involved a qualitative survey of both
medical professionals and ordinary citizens who hadreceived medical care, concerning the forms of medicalcare that are likely to emerge and the new types of work
to be carried out by medical professionals after the
implementation of AI, with the goal of acquiring greater
knowledge related to this topic.
MethodA method of philosophical discussion was used toacquire relevant knowledge related to emerging forms of
medical care and changing work demands among
medical professionals after the implementation of AI.
This method involved a combination of Neo-Socratic
Dialogue (NSD) and Transfer Dialogue (TD) techniques.
NSD is a philosophical discussion technique createdby the German Kantian philosopher Leonard Nelson(1882–1927) in the early 20th century. It has seen
widespread use in European countries such as Germany,
the United Kingdom, and the Netherlands, and was firstutilized in Japan in 1999 (Aizawa K. et al., 2010).
Although NSD is a technique normally used for
discussion in philosophy and ethics education, the factthat its methodology is based on having participantspresent their own personal cases related to a theme andconduct their own analyses of applicable cases has
enabled its use both in Japan and elsewhere as part ofqualitative surveys related to questions similar to the
topic of this study, such as, for example, “What work do
medical professionals perform related to patientdecision-making?”(Horie T., 2008). TD is a discussion
method that tests the kind of understanding andknowledge gained through application of generalprinciples and decision-making processes acquired from
NSD to real-world contexts. This method consists of agroup discussion where participants can speak freely on
an applicable theme based on their newly acquired
knowledge and progress after NSD has been completed.
The approach of combining TD with NSD was developed
as a “Dialogue Complex” by the Department of Clinical
Philosophy, Osaka University Graduate School of Letters(Horie T. & Homma N., 2003, Horie T., 2004, Homma N. &Horie T., 2010). Furthermore, a study similar to this one
has been conducted in Austria, consisting of a survey of
medical personnel and ordinary citizens on the theme of“genetic counseling and self-determination”. As with thatstudy, the current study used a combination of NSD and
TD. In addition, while only the participants and afacilitator participated in the discussion during the NSD
phase, researchers in attendance also participated in the
TD phase.

231

For this study, each survey consisted of 1.5 days of NSD
and 0.5 days of TD, for a total of 2 days, and involved 5-6
participants. The participants were specialists inmedicine and related fields, such as doctors, nurses,
medical social workers, pharmacists, and psychologicalcounselors, and ordinary citizens receiving medical care.
The theme of the NSD session was “What are medical
professionals doing for patient decision-making?”, while
the theme of the TD session was “How should medical
professionals approach their work after the introductionof AI?”.
Statements made during the NSD and TD sessions
were recorded, and a transcript was created afterwards.
This report qualitatively analyzed the TD transcript only.
In addition, this study was implemented based on an
evaluation of the Tohoku University School of Medicine
Ethics Committee and with the approval of the dean of
the graduate school (2018-1-778).
Results
Two surveys were conducted in 2018 (13–14 Januaryand 11–12 August). There were 11 participants in total,
comprising doctors, nurses, a pharmacist, a speechhearing therapist, a psychological counselor, andordinary citizens. Tsuyoshi Horie served as the facilitator
for both surveys. Information about the participants isrecorded in Table 1, and Table 2 provides an overview of
NSD.
The main points raised during TD were classified into
5 categories: i) Functions which AI could perform andthose that would be difficult for AI to perform, ii)
Changes in medicine caused by AI, iii) Preparations
which need to be carried out for the application of AI to
medicine, iv) Concerns about AI, and v) Other.
Category i) mostly involved discussion concerning theextent to which the medical care currently carried out by
medical professionals could be performed using AI andthe kind of functions that would be difficult for thistechnology to perform. Providing standard medical careand relevant medical field information, which can bereadily converted to language or data, were identified as
possible functions for AI, and many of the participants
stated that running the process from diagnosis to
proposing a course of standard care treatment was a
possibility for AI. On the other hand, functions difficult tobe converted into language or data, such as expert
experience and judgment, insights, handling existential
problems, consideration for individual patient
conditions, and appropriateness in patient care wereconsidered challenging for AI. In addition, concerns
regarding excessive AI information collection andanalysis leading to unwelcome medical intrusivenesswere raised. In the debate on greater AI use, while somewere of the strong opinion that there would always be
areas where AI could not be applied effectively, others
expressed the view that people’s expectations frommedicine itself would change, and they would beaccustomed to a new system in which AI could work
more effectively. Although consideration for humanspecific subtleties in medical care was identified as anarea which would be challenging for AI, others also
stated that the emotionless and fatigue-free nature of AI
would make it better suited to some situations thanhuman workers.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

Concerning category ii), the participants identified
possible changes in the relationship between patientsand medical staff, structuring of medical experts’ work,and overall approach to medicine itself. Regarding therelationship between patients and medical staff, theparticipants considered the role AI would likely play inthe relationship between the two parties, with threecontrasting viewpoints identified as follows: “Medical
staff will have exclusive access to AI and interpret its
analysis content,” “Both patients and medical staff will
have access to AI analysis content, but the medical staff
will be expected to interpret, explain, and provide
support,” and “Patients and medical staff will have equal
opportunity to interact with AI analysis.” Theparticipants were split relatively evenly across theseviewpoints, and they further pointed out that there
would likely be individual differences in the degree towhich people were able to accept the technology,
depending on the age groups involved and individual
factors. In addition, many felt that applying AI within the
medical care team could facilitate a more open dialogue.
Concerning the structuring of medical care, someparticipants considered that specialist positions would
remain subdivided into occupations such as doctors andnurses, while others saw the potential for unification
into a single “medical staff” grouping. Further,
participants pointed out that, through advances in theindividual usage of AI and wearable technology, theprocess of gathering and analyzing medical data could
itself change, possibly causing a shift in the overall
approach to medicine itself, especially in relation to
medical deduction and diagnosis.
Regarding category iii), the discussion focused on the
responsibility for considering the information provided
by AI for diagnosis and other functions as the applicationof AI within medicine progresses. The extent to which
doctors need to be considered responsible for taking thisinformation into account and the degree to which
patients need support in this area from the medical staff
were points of debate, and the necessity of patientsthemselves to be informed concerning their own
advanced medical information as obtained through AI in
relation to medical care was also discussed. Regarding
future decision-making, given the remaining areas of
uncertainty and with AI increasingly involved with thepresentation of diagnoses and standard medical care, theparticipants discussed the extent to which patientswould be able to understand the relevant information,
the kind of literacy necessary for this purpose, and thekind of support required from relevant professionals.
Some pointed out that relevant education, awareness of
ethical considerations, and deeper engagement withissues of life and death will probably become moreessential for a broader range of people in society than ispresently the case. Participants also noted that, in termsof AI development, the developers need to have a greater
understanding of medicine and medical ethics.
Regarding category iv), concerns were presented
related to the black box aspect of AI deep learning.
Participants raised concerns such as the possibility of AI
moving out of control, perhaps even working against
human interests like some form of Frankenstein’s
monster, or the distortion of learning and analysis
orientation, regardless of the intentions of the AI

developers. Further, although human medical staff arelikely to work to save the lives of patients, even if theirreturn to society could be difficult, participants raisedquestions concerning the necessary steps to be taken if
AI systems determined that care for these kinds ofpatients was illogical. In addition, they considered that,as AI continues to advance, pressure could mount tomake wearable devices compulsory.
Regarding category v), many fascinating opinions
were shared on other topics as well. For example, theparticipants reflected on whether AI might give patientsadvice like “you can give up on treatment, if you like” andpointed out that transferring medical care to AI mightallow possibilities for mankind to discover new kinds ofwork and that the development of AI could be an
opportunity to rediscover our humanity andopportunities for greater collaboration. Participants also
contemplated whether AI could experience death and , inreplicating the experiences of a dying person, could
provide useful training material for human medical staff
members in caring for critically ill patients.
Discussion
The knowledge acquired through the results of these twosurveys can be divided into two categories related to theapplication of AI to medicine, namely, the changes that
medicine and medical staff will likely face in future, andthe preparations needed for these changes.
Regarding predictions for medicine after the
implementation of AI, the fundamental perspective
participants adopted was to consider those aspects that
could be undertaken using AI, and they concluded thatthe current state of medicine will be dramaticallychanged, with the possibility that it could take on an
entirely new form that goes beyond the question ofwhether AI can or cannot take over various functions.
Whether a more limited or a more radical viewpoint on
the possibilities of AI was adopted can be interpreted as
occurring in relation to whether a short-term or longterm outlook was used. Even if a division of functions
among AI and human workers was implemented within
the current framework of medicine in the near future,
the framework of medicine itself could still change more
dramatically over a longer period. Furthermore, given
the rate at which genome analysis technology has
progressed in the past few decades, there could betechnological changes that go beyond our imaginationeven in a very short period of time, and it is quitepossible that both medicine and society itself couldchange along with their arrival. When considering
medicine after the implementation of AI, an openminded
and imaginative approach is likely to be of value incoping with the resulting process of change.
Table 1: Number of participants in NSD/TD and theiroccupation
Occupation
Doctor
Nurse
Pharmacist
Speech-hearing therapist
Psychological counselor
Ordinary citizen

Number of participants
2
3
1
1
1
3

Table 2 Overview of NSD
First session (Jan. 13–

Second session

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
NSD
questions
Examplespresented
and sharedbyparticipants

Answers toquestionsafter
examining
the cases

14）(Aug. 11–12）
What work do medical professionals
perform related to patient decision-making?
A case related to
A case of refusing a
examinations for mild
blood sample to bechest pain and its
taken for surgery
handling by doctors:
preparation: fromfrom the patient’s
the patient’s
perspective. At theperspective. At thefirst hospital, because
autologous bloodthe doctor
donation stage in
immediately
surgery
recommended a
preparations, thecardiac catheter test,
patient stated, “I
the patient felt uneasy
want to go home,”
and canceled theand refused to
examination. However, allow the taking ofat the second hospital,
a blood sample.
the doctor listened
However, thecarefully to what the
blood waspatient had to say, and successfully
as a result, the patientcollected when thefelt confidence in thenurse and doctor
diagnosis given based
intervened.
on the follow-up
observation results.
If medical
・Medical staff act aspersonnel receive
partners to work out
tentative consent
patient concerns andfrom the patient
expressing thisbased on a
attitude to the patient.
standard
・They identify thetreatment plan,
information patients
their final
need to make aintention is todecision for sharedcarry out this plan.
concerns with
Means ofreference to medical
supportingknowledge anddecision-making inexperience.
this process: 1)
・They clarify sharedshare informationinterests andrelated to illness
comprehension
and treatment, 2)
through theconsider the bestinteraction of the
medical approachinterests andfor the patient, 3)
understanding of theshowpatient and theconsideration for
medical staff.
each patient and(This represents aeach case, 4) show
selection of theunderstanding andmultiple answers
compassion
received.)
related to patientconcerns, 5)
indicate
information andchoices bearing in
mind the patient’s
everydaycircumstances,
lifestyle, andquestions, and 6)
for all categories of
personnel torespond topatients in aconsistent manner.

However, the perspectives and assumptions revealedin this study almost certainly involve some limitations,233

and determining an effective approach in relation to theeffects of AI in the medical domain requires a willingness
to not be bound by rigid thinking. In another study, we
have already considered what else may be required
based on literary research (Asai A. et al., 2019). The
findings of these surveys suggest that initiatives topromote the acceptance of each individual in society andappropriate technological development are essential tothe process of preparing for the changes in medicine
following the implementation of AI. These preparatory
conditions for the application of AI technology to
medicine cannot be limited to medical professionals, andmust extend to workers across all disciplines and tosociety as a whole.
Funding
Our paper has been written under the support of Human
Information Technology Ecosystem [HITE]. HITE is a
research and development [R&D] focus area delivered by
the Research Institute of Science and Technology forSociety [RISTEX], Japan Science and Technology Agency[JST].
References
Aizawa K. et al., A Neo-Socratic Dialogue for developing amutual understanding of rights and responsibilities in thehealthcare system, Contemporary and Applied Philosophy
2010; 2: 1-16.
Asai A., Okita T., Enzo A., Ohnishi M., Bito S. Hope for the bestand prepare for the worst: Ethical concerns related to theintroduction of healthcare artificial intelligence. Eubios
Journal Asain and International Bioethics 2019;29:64-71.
Homma N., Horie T., Trail Application of the “Dialogue
Complex” on the Theme of In-Home Medical Care. In: The
Challenge of Dialogue: Socratic Dialogue and Other Forms of
Dialogue in Different Political Systems and Cultures, Part
Two: Dialogue in Different Contexts and Political Systems,
p.293-306.Jens Peter Brune (editor), Horst Gronke (editor),
Dieter Krohn (editor), 2010.
Horie T., Homma N., “Dialogue Complex: Preparations for thedevelopment of a clinical communication model,” 20022003 Ministry of Education, Culture, Sports, Science andTechnology, Science and Technology Promotion
Coordination Fund, Science and Technology Policy
Declaration, 2002 Report, “Development and application ofa clinical communication model,” pp. 144-163, March 2003.
[in Japanese]
Horie T., “Public dialogue method: Testing of dialogue Complex
for the theme of home medical care activities,” 2002-2003
Ministry of Education, Culture, Sports, Science andTechnology, Science and Technology Promotion
Coordination Fund, Science and Technology Policy
Declaration, 2003 Final Report, “Development andapplication of a clinical communication model,” pp. 34-46,
March 2004. [in Japanese]
Horie T., “Research survey of ‘dialogue participation type’
genetic counseling: Neo-Socratic Dialogues conducted in
Vienna and Osaka,” Grant-in-Aid for Scientific Research
Foundational Study B 2004-2007: Considering theEffectiveness of a New Public Conversation Model, pp. 4357, March 2008. [in Japanese]

The COVID-19 pandemic and social
inequality

234

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)- Christopher Ryan Maboloc, PhD
Ateneo de Davao University, the Philippines
Email: ryanmaboloc75@yahoo.com-Carmelle Ayra Ferrer, MD
Southern Philippines Medical Center

This paper addresses an important point with regard to
the critical question of equality during a pandemic – arepoor societies more vulnerable to public healthemergencies? The available data with respect to thecoronavirus crisis reveal that the majority of countries
affected by the pandemic belong to the developed
economies. This investigation determines the correlation
between affluence and the spread of the contagion. It
argues that the inequality among nations does not haveany significant relation to disease movement, infection,and high mortality rate. However, addressing the
problem of urbanization and investing in public healthwill be crucial in terms of confronting the socioeconomic ramifications of the COVID-19 pandemic.
Introduction
Human societies have been devastated by wars in times
past. The Second World War, the greatest conflict in thehistory of humankind, has killed more than 100 million
lives. Societies have been destroyed by the whims of
dictators. Famines have cause unimaginable misery andsuffering to millions of human lives and death tocountless people. Pandemics are no different. Suchoccurrences kill lives and at the same time also present
themselves as hard challenges that humanity mustreflect on if it must survive. Thomas Abraham (2011, 3)
explains that questions about a pandemic are not justabout health, but its political and social consequences as
well.
Pandemics, by definition, refer to disease outbreaks
that affect all people. The important features to consider
to characterize any disease outbreak as a pandemic
include “wide geographic extension, disease movement,
novelty, severity, high attack rates and explosiveness,minimal population immunity, infectiousness andcontagiousness.” (Qiu et al. 2016, 30) History reveals
how pandemics have caused havoc to human lives. The
death tolls number from thousands to tens of millions.
Some of the pandemics recorded in modern times
include “smallpox, cholera, plague, dengue, AIDS,
influenza, severe acute respiratory syndrome (SARS),
West Nile disease and tuberculosis.” (Qiu et al., 4) The
most difficult to predict among them and perhaps, themost dangerous considering the very high mortality
rates are influenza pandemics that have been in
existence since the 1500s. The Spanish Flu of 1919 has
killed 50 to 100 million lives, for example.
The COVID-19 pandemic has killed 190,654 with a
total confirmed cases of 2,718,699 cases as of April 23,
2020. The highest death toll is in the United States with
49,855 fatalities of 880,204 cases. Italy has 25,549
deaths of 158,183 cases. Spain has 22,157 deaths of
213,024 cases, higher than that of Italy. Outside Europe
and Northern America, Iran recorded the highest
number of deaths at 5,481 of 87,026 cases. (JHU 2020)
Disease movement

The coronavirus pandemic has spread rapidly. It began
in Wuhan, China and entered the Western hemisphereimmediately. As of the moment, China has eased
restrictions while the United States is grappling with theright steps to make as some states are now eager toreopen their economies against the advice of top US
health experts. According to Dr. Anthony Fauci, the only
way to reopen the economy is to ramp up testing inorder to protect the population.
The COVID-19 is a respiratory disease. Given that
SARS-COV2, the virus that causes the disease, can spreadfrom person to person, social or physical distancing is amust to protect the population. Overcrowded places suchas transport hubs, malls, and office buildings, publicparks and places where people converge act as a naturalenvironment where individuals get the viral infection.
Experts note that the coronavirus can live up to 48 hours
in some surfaces and can remain suspended in the air fora longer period of time.
One of the contributory factors to the rapid
movement of the outbreak is globalization. (Maboloc
2020, 77) The interconnected nature of our globalized
economy means that the easy movement of peoples
across the planet enabled the fast pace of human tohuman transmission. But it must be noted that while thedisease has reached the African continent, the record
shows that the infection is not as widespread as inEurope and Northern America.
For instance, South Africa recorded 75 deaths of
3,953 cases. Egypt has 287 fatalities of 3,891 confirmed
cases. Ghana has nine (9) deaths of 1,154 cases. Nigeria
has 31 deaths of 981 cases. Tunisia has 38 deaths of 918
confirmed cases. Senegal has recorded only 6 deaths of
479 cases. The Democratic Republic of Congo (DRC),
which recently had an Ebola outbreak, recorded 25
deaths of 377 cases. (JHU 2020)
In Southeast Asia, Indonesia has the highest numberof deaths at 647 of 7,775 confirmed cases; thePhilippines recorded 462 deaths of 6,981 recorded cases
while Malaysia has 95 fatalities of 5,603 cases. Singapore
has the highest number of cases at 11,178 but has thelowest number of deaths at 4. Most cases recorded in the
country come from its migrant labor force. Vietnam, it isworth mentioning, has zero deaths of 268 recorded
cases. (JHU 2020)
It may be concluded from the above that thecoronavirus infection affects more people in the Western
hemisphere and especially, affluent societies. In contrast,
the disease seem to be recording slow levels of infectionsin poorer regions such as Sub-Saharan Africa andSoutheast Asia. Experts note that the South Korea has
been efficient in containing the spread of the virus
through testing, tracking, and tracing.
Infection and mortality rates
Diseases that have low infection rates are not classified
as pandemics. The Ebola virus, in contrast, has been
noted for its severity, infectiousness, and high mortality
rate. (Qiu et al. 2016, 5) Severity is estimated by the casefatality ratio. (Donaldson et al., 2009) Wu Qiu, et.al
writes that “the Ebola outbreak was an unprecedented
public health emergency of international concern with
28,581 cases and 11,299 deaths in West Africancountries.”Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
The implication to human health “lies in the potentialof the virus to mutate into a form capable of sustained
person-to-person transmission.” (Qiu et al. 2016, 5) Thisis precisely the case for the SARS-COV2 virus. Leading
science journal Nature reports that “although hopes for
antibody-based immunity are high, there is currently
little available data on whether human populations
develop immunity to SARS-CoV-2.” (Nature, April 10,
2020)
In comparison, the dreaded Ebola virus has an
estimated fatality rate of 40%. (Nabarro & Wannous,2016) The Ebola emergency required international
cooperation to contain its spread in Sierra Leonie andthe DRC. The disease first appeared in South Sudan andthe DRC, near the Ebola River, where its name was takenfrom. According to the World Health Organization, “thecurrent 2018-2019 outbreak in eastern DRC is highly
complex, with insecurity adversely affecting publichealth response activities.” (WHO 2020) After reportingthat the outbreak has been contained this year, a newcase of the virus recently emerged in DRC.
WHO (2020) says that the death rate for COVID-19 is
at 3% whereas the seasonal flu is at 1%. The WHO
however is cautious as to this early estimate given thatthe total number of unreported cases remain unknown,
especially in China. Thus, the international body has
stated that “the only number currently known is how
many people have died out of those who have beenreported to the WHO.”As of April 23, 2020, the death rate in the US is
currently at 5.7% whereas it is 6.6% in the Philippines;
the death rate in Italy is 13.4% while it is at 3.6% in
Germany; in China, the death rate stands at 5.6% (figures
already revised from the previously reported); in South
Africa, the mortality rate is at 1.8% compared to 6.3% in
Iran; Indonesia’s mortality rate for COVID-19 stands at
8.3% whereas it is at 1.7% in Malaysia. (JHU 2020)
Based on the above, it may be assumed that thepersistent inequality among nations has no significant
influence when it comes to the spread of the disease, its
contagion or infectiousness and its mortality rate whichshows a wide disparity between affluent states andcountries in poor regions, although the Philippines andIndonesia show some variance.
It has been suggested that COVID-19 can spread
rapidly in densely populated areas. This may be true inthe case of the Philippines where the volume of cases
have been concentrated in the National Capital Region,
Cebu in Central Visayas, and Davao City in Mindanao.
The said places have a high concentration of people whocome to malls, transport hubs, and public areas.
While the whole Davao Region has 97 confirmed case,Davao Occidental which is 135 kms away from Davao
City, has not recorded a single case of the coronavirus.
(DOH 2020) By implication, the geographic configurationof the Philippines, lack of accessibility, and distance fromairports and dense population have a significant
correlation to disease movement. Cebu City, for instance,
like Metro Manila, has an international airport withregular weekly flights coming from China, South Korea,
and Japan.
Social inequality and pandemics

235

There appears to be no known reliable statistical datawhen it comes to the correlation between past
pandemics and social inequality. The literature only
suggests a few surviving anecdotal narratives whichcannot be validated. It is widely known, for instance, thatthe plague that hit London in the 16th century
decapitated a big part of the poor who lived in the slums
while the affluent part of society were separated fromthe area where the plague emerged. Given the
restriction, thousands of poor people died in their homes
while being quarantined.
Chronic (non-communicable) diseases like cancer,
heart or lung disease, offer some information as to thesusceptibility of the population. Poor people lack accessto quality health care and often do not have the means to
procure medicine or available treatment. People do notjust die from diseases. They die because of inefficiency
and the lack of immediate care that is supposed to beprovided by the state. The WHO (2020) explains:
The poor are more vulnerable to chronic diseases
because of material deprivation and psychosocial stress,
higher levels of risk behaviour, unhealthy living
conditions and limited access to good-quality health care(see sidebar figure on the next page). Once disease isestablished, poor people are more likely to suffer
adverse consequences than wealthier people. This isespecially true of women, as they are often more
vulnerable to the effects of social inequality and poverty,
and less able to access resources.
The COVID-19 pandemic is feared to have a major
health impact in impoverished nations. However, as theabove show, that appears to be unfounded as of the
moment. Social inequalities, it is suggested by some, giverise to pandemics. But such is not currently the casebecause as a matter of fact, COVID-19 is affecting
developed countries more than the impoverished states.
Internally, urban centers suffer the most in terms of ahigher rate of infection compared to rural areas where
people are spatially separated.
In the United States, data show that Black Americans
have a higher death rate compared to Whites or Latinos.
The disproportion can be examined by comparing thepercentage of deaths to the population. (APM 2020)
According to the APM Research Lab, “across the U.S.,
Black Americans are dying of COVID-19 at a rate of morethan twice the population share.” The data shows that“collectively, they represent 11% of the population instates releasing data, but have suffered 28% of deaths.”(APM 2020)
The disproportion can be attributed to pre-existing
conditions rather than race or a person’s economic
states of affairs. The coronavirus, indeed, respects noeconomic or regional boundaries of borders. Battling the
pandemic, policy-wise, should be about the
epidemiological attributes or characteristics of thedisease although it is without argument that the unequal
or unfair conditions of human beings in society may
contribute to the problem, as acknowledged by Dr. Fauci.
Referring to the situation of African-Americans, heexplains:“And the reason I want to bring it up, because I
couldn't help sitting there reflecting on how sometimes
when you're in the middle of a crisis, like we are now withthe coronavirus, it really does have, ultimately, shine a236

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)very bright light on some of the real weaknesses andfoibles in our society.” (Business Insider, April 8, 2020)
The current statistics reveal that in New York City,
47.7% of coronavirus deaths belong to the 75 and above
age bracket, 24.6% for (65 years old to 74 years old),
23.1 for (45 years old to 64 years old), and 4.5% for (18years old to 44 years old). The sex ratio for deaths in
New York City, which has become the new epicentre of
the pandemic, is at 61.8% for males and 38.2% forfemales. (New York City Health Daily Data Summary
2020)
Globally, with respect to pre-existing conditions, thefollowing are the co-morbidity rates for those infectedwith COVID-19: 13.2% for cardiovascular disease, 9.2%
for diabetes, 8.0% for chronic respiratory disease, 8.4%
for hypertension, and 7.6% for cancer. (Worldometer
April 16, 2020) Doctors and experts are in agreement as
to how pre-existing conditions may hugely contribute tomortality outcomes.
The conclusion based on the above data is that
individuals with pre-existing conditions are more
vulnerable to COVID-19. The basic point is that social
inequality presuppose that the many members of poor
communities are disproportionately served in terms ofhealthcare and for this reason, the unequal condition ofpeople is a threat to their health which may result todeath.
The coronavirus does not choose who becomes ill.
But unjust structures and the uneven social conditions
within the areas where the disease movement isprevalent may reveal who might succumb to theinfection. On the other hand, people who are spatiallyseparated from cities with density of people or places
where economic activities require the convergence oflarge crowds might find themselves safe from thecontagion for now.
On Non-Covid Cases: A Short Note
But health care professionals face other challenges.
There are non-COVID 19 patients who cannot bedischarged or easily transferred to another hospital due
to health protocols imposed by the government, and we
can see that in the Philippines. The Southern Philippines
Medical Center (SPMC) is a case in point. The reason
cited by public health and government officials is public
safety and the need to contain the local transmission of
the virus.
The social aspect of the problem has also made itself
manifest. For example, health care workers such as
nurses, attendants and others are discriminated by thecommunity. Reports say that they are asked to leave
their rented places and public transportation would
drive past them as they are identifiable by way of theiruniforms. Also, doctors at the government run hospitalcannot do elective cases which are beneficial to patients
because all services will only allow STAT or emergency
procedures.
Some of the facilities inside the hospital complex at
SPMC have been used for Persons under Investigation(PUI) and these cannot be used for non-COVID patients.
Blood donations are suspended and blood banks orcenters experience shortages. Other patients who sufferfrom a different condition in need of blood or require
certain medications face risks and challenges. The

essence of holistic care is a bit compromised but doctors
also feel that they cannot blame the institution. The
public health situation at this time simply requires extra
measures.
The services that hospitals can offer would require agreater form of sacrifice. It is the sentiment of frontline
health care workers that they should not be left alone tocarry the burden. Some questions linger: “How does one
give care when patients in need of platelet concentratecannot borrow blood?”, “What if the donors are outside
the local quarantine zone?”, “These some questions thatneed to be asked inside during emergency cases for nonCovid patients.”
Policy change in a post-pandemic scenario
The coronavirus has revealed harsh social pathologies.
The unequal situation of people, the lack of access toquality healthcare for the treatment of chronic diseases,
tend to exacerbate the condition of people in areas
where the contagion is widespread. This means thatsome things should be done on the part of government
and policy makers post-pandemic to improve theapproach in combating a possible second wave.
From a global perspective, governments are
witnessing the failure of systems to protect national andregional economies, with some countries in Europe
expected to suffer from an 8% to 15% Gross Domestic
Product (GDP) contraction. The United States has
basically wiped out the 24 million jobs that it has createdin the last ten years, with more than 26 million
Americans filing for unemployment claims as of the
moment. In the Philippines, 400,000 families expect hardtimes as the same number of overseas Filipino workers
will lose their jobs.
It can be said that untamed growth due to rapid
urbanization is one of the culprits in the fast spread of
the virus. Prospectively, densely populated cities should
be re-designed as a strategic measure to prepare thepopulation for the possible second wave. Since people go
where the jobs are available, government centers can be
relocated to the provinces. In addition, small andmedium enterprises must be set up away from urban
centers to create more jobs and spur economic growth inrural areas.
To address inequities in health care, existing healthcare policies should consider the most vulnerable
member of the population. Universal health care shouldbe implemented. As what this pandemic reveals, if only
governments invested more in public health, deaths
could have been prevented or reduced. By improving thequality of health care services, people will be better
equipped to combat the movement of the disease.
The University of Oxford is first to report on humantrials for a potential coronavirus vaccine. At present,
there are at least 80 undertakings on vaccine
development. A vaccine is expected to be delivered
between 18 months to two years. Mapping thecoronavirus gene in January 2020 has helped accelerate
the development of the vaccine. However, experts are
cautious in terms of the timeframe, insisting that
protocols should be followed to make the vaccine safe.
Vaccines should be developed as a collaborative
effort of international bodies. In this way, access to theprotection from the coronavirus can be made available

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
even to the poorest regions in the world. While
substantial financial incentives await researchers, thefact of the matter is that pharmaceutical companies will
be quick to jump on the occasion once a vaccine is foundand profit from a potential windfall. This should be
prevented through international pressure.
Politically, governments around the world must
recognize the importance of health care as an integral
component of human development. Doctors and othermedical front liners should be duly recognized theirsacrifices. Most states have invested billions of dollars inmilitary upgrade but have neglected public health. Andso, it is the case at of the moment that the grave threat to
public health has shown itself as a real challenge.
The coronavirus pandemic reveals that everything inlife is a symphony. In the absence of a part of a whole,
the symphony of human life would collapse. In our
modern times, people have poured a great part ofthemselves in pursuit of economic prosperity. Now,
societies realize that all of that can fall into pieces if
authorities neglect the total well-being of people. Above
all else, human life is what matters in the end.
Conclusion
This study has sought to determine the correlation
between social inequalities and the impact of pandemics
to society. The correlation is not significant. The virus
chooses and respects no economic or social boundaries.
Given this, governments must guarantee the kind ofenvironment in which people are safe and secure. By
this, we do not only mean the protection of people withrespect to the threat of the coronavirus disease, but theirsocial and economic welfare as well. For that matter,
preparing people in a post-pandemic world will require
the bold re-channelling of resources. Government must
invest more in public health. Prospectively, urban
centers should be redesigned. The coronavirus teaches
us that there is something greater than the economic
aspect of life. And that is human life itself as primordialor fundamental value above all else.
References

Abraham, T. 2011. “Lessons from the pandemic: the need for
new tools for risk and outbreak communication.” In
Emerging Health Threats Journal, Volume 4, Number 1: 1-4.
APM Research Lab. 2020. “The color of Coronavirus.”
https://www.apmresearchlab.org/covid/deaths-by-raceBusiness Insider. April 8, 2020. “Dr. Fauci says coronavirus isshining bright on unacceptable disparities for AfricanAmericans.” https://www.businessinsider.com/fauci-covid19-shows-unacceptable-disparities-for-african-americans2020-4
Department of Health (Philippines). April 24, 2020. “Updatesonthecoronavirus
disease(COVID-19).”
http://www.doh.gov.ph/2019-nCoV
Donaldson, L. J., Rutter, P. D., Ellis, B. M., Greaves, F. E., Mytton,
O. T., Pebody, R. G., & Yardley, I. E. 2009. Mortality frompandemic A/H1N1 2009 influenza in England: Public Health
Surveillance Study.
Johns Hopkins University. 2020. Coronavirus Resource Center.
https://coronavirus.jhu.edu/.
Maboloc, C.R.B. 2020. “Globalization and Consumer Culture:
Social Costs and Political Implications of the COVID-19
Pandemic.” In Eubios Journal of Asian and International
Bioethics, Volume 30, Number 3 (April 2020): 77-80.

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Nabarro, D. and Wannous, C. 2016. “The Links between Publicand Ecosystem Health in Light of the Recent Ebola Outbreaks
and Pandemic Emergence.” In EcoHealth: 1-3.
Nature. April 24. 2020. “Covid-19 Research in Brief.”
https://www.nature.com/articles/d41591-020-00009-x
New York City Health. “Covid-19 Daily Data Summary.”https://www1.nyc.gov/assets/doh/downloads/pdf/imm/co
vid-19-daily-data-summary-deaths-04152020-1.pdf
Qiu, W., Rutherford, S., Mao, A., and Chu, C., 2016 and 2017.
“The Pandemic and its Impact.” In Health, Culture andSociety, Volume 9 and 10: 1-10.
Worldometer. April 16, 2020. “Age, Sex, and Existing
Conditions
ofCoronavirus
deaths.”https://www.worldometers.info/ coronavirus/coronavirusage-sex-demographics/
World Health Organization. 2020. “Chronic Diseases and Health
Promotion.”
https://www.who.int/chp/chronic_disease_report/part2_ch2/en/index1.html
World Health Organization. 2020. “Ebola Virus Disease.”https://www.who.int/news-room/fact-sheets/detail/ebolavirus-disease

COVID-19 Age: Spirituality and Meaning
Making in the Face of Trauma, Grief andDeaths- Rogelio P. Bayod, Ph.D.
Cor Jesu College, the Philippines
Email: roger.bayod@gmail.com
Abstract
The COVID-19 outbreak is affecting not only the way
people live but also the way people die, the way people
handle their dead as well as their different “death”
experiences. The different governments throughout theworld have their own guidelines to follow in terms ofmanagement of dead bodies. But these guidelines aremostly focused on protecting the living from being
contaminated with the virus. In many cases during
emergency situations, dead bodies are no longer
considered sacred and treated with utmost respect. On
the contrary, they can even be a source of worry and fear
for the government and also for some people. However,for the families and loved ones of the deceased, paying
their last respect for the dead is an important part of theprocess of grieving, saying goodbye and accepting thefact that life here on earth is just temporary. This paperargues that in any corpse and “death” management evenduring emergency situations, a dialogue with culture,spirituality, faith and belief systems of the people as wellas insights from psycho-therapists such as Joyce Rupp,
Elizabeth Kubler-Ross, Victor Frankl and even theteachings of Jesus Himself, can be an important resourcein helping the people cope with the loss of their loved
ones and in dealing with their dead members of thefamily as well as their own “death” experiences during
this pandemic.
Keywords: Finding Meaning, Spiritualty, Corpse
Management, Goodbyes, Grieving, Covid-19.
Introduction
The journey of life is always filled with stories of gains
and losses, pains and joys, life and death. In normal

238

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

scales, they make our life colorful and beautiful.
However, in emergency situations, too much pains andsufferings especially involving losses and deaths maylead a person to emotional despair and trauma. The
purpose of this paper is to discuss how COVID-19
pandemic affects not only the way people live but also
the way people die - be it physically, emotionally or
spiritually, as well as the way they handle these different
forms of death.
To be able to do this, first, we will try to explore how
the governments (the most powerful actors) in different
countries help their constituents in dealing with thepsycho-spiritual impact of the Covid-19 especially tothose people who have encountered physical death oftheir loved ones and family members and also their own“death” experiences. How are they coping up with thisloss and its underlying emotions? How did thegovernment help them? How are they saying goodbyes
to their loved ones and family members during thispandemic situation? What could be the things that keepthem to continue choosing “life” instead of “death”
during this very challenging time? These are some of thequestions that this paper tries to answer.
Lastly, this paper will try to offer a kind of psychospiritual insights gained from my personal experiences
as a counselor and a spiritual director and also with theworks of Joyce Rupp, Elizabeth Kubler-Ross, Victor
Frankl and other psycho-spiritual therapists, and eventhe teachings of Jesus Himself on how to deal with ourdifferent experiences of goodbyes and letting go as we
journey towards living a new life in the newenvironment brought about by Covid-19 pandemic.
Living, Death and Goodbyes
In her book, “Praying our Goodbyes”, Joyce Rupp reminds
her readers that goodbyes are part of our life as theseason of the year. She even puts theological or spiritual
dimension in the human experiences of good byes. For
Rupp, the word goodbye can be interpreted as “God-bewith-ye” or “Go-with God” (Rupp, 1988: 17). By taking
God as a significant companion in the journey, Joyce
Rupp wants the travelers and even the one sending themfor that journey not to fear because even if the journeygets tough, there is hope and consolation in the thoughtthat God is with them always. In other words, goodbye
can be a blessing of love and also hope in the belief thatsince God journeys with you, you will never be alone.
How about those whose loved ones succumbed todeath because of accidents and disasters? Did they havethe same thinking about death? Were they able to say
goodbye to their loved ones and ensure them that God iswith them in journey?
While most people ensure that their loved ones will
experience “good death” and provide best funeralservices to prepare them for their journey to another life
and to comfort themselves for the loss of their loved
ones, that practice and its accompanying rituals in
different cultures have not been followed during
emergency situations. For example, during Typhoon
Pablo that hit Mindanao in the first week of December
2012, I saw a lot of dead bodies wrapped in plastic bags
being put along the roads in New Bataan, Compostela
Valley Province (now, Davao de Oro Province). To avoid
decomposition, they were buried immediately in mass

graves. The families who were still battling for survival
and helping the responders to look for their other family
members who are still missing, had no time to prepare agood funeral service for their loved ones. They did noteven have the time to mourn for their death. Their
immediate concern was to ensure that their other family
members are still alive and they have a place to stay as
their houses were ravaged by the raging waters andlandslides.
This was also the experience of a lot of survivors
during the Typhoon Haiyan, locally known as Yolandathat hit the Philippines most particularly, Leyte on
November 8, 2013, causing the death of more or less ten
thousand people. Sharing his experiences as a head of
the Redemptorist Mission Team that responded to
Yolanda disaster, Brother Karl Gaspar (2014) narrated
how the government treated the dead bodies – they wereburied together in different mass graves, other were
unidentified and unclaimed. The most dramatic
graveyard mentioned by Gaspar is that of Pedro
Lacandoz’ family whose 22 members of his extended
family perished in that deluge (Gaspar, 2014: 44). The
survivors of this Mega disaster were not able to provide
best funeral service to their loved ones.
This awful event further traumatized the victims ofdisasters (Gaspar, 2014). There is no “good death”
during disaster. In fact, the death that people
experienced during disasters such as typhoon, landslides,
earthquakes and wars can be considered a violent death.
Gaspar (2014) even says that that this kind of death is noless violent than Jesus’ death by crucifixion. During thepsycho-social interventions what we conducted with the
Typhoon Pablo survivors, they shared about theirhorrible experiences as thy witnessed their loved ones
struggled to live, asking for help but they could not help
them. These heartbreaking stories of the Typhoon Pablo
survivors were confirmed by the experiences of Gaspar
during Typhoon Yolanda that these stories, are indeed
heartbreaking and that even the most highly trained andexperienced counselors and psychologists can reachsaturation point after hearing one horrific story after
another (2014: 46).
In the two scenarios mentioned above, althoughdeath was considered violent and the family members
did not have the time to mourn for their dead, they werepermitted to come closer, kiss and caress their loved
ones whenever they were available. While many of themwere not able to do these because of the situations, somewere able to perform (albeit in such a hurry) thenecessary rituals to say their goodbye and prayer totheir dead and wish them luck in their next journey. But
this is not the case now with Covid-19. In many parts of
the world today, a lot of dead persons are cremated andburied without the presence of their family members
and loved ones. This caused a lot of emotional distress tothe members of the family who were not able to provide
care and emotional support before their family members
died and also their presence during their death (LaMotte,2020).
Corpse Management in Different Countries During
COVID-19 Pandemic
The Covid-19 pandemic exposes the unpreparedness ofmany countries (even the advanced ones) not only inEubios Journal of Asian and International Bioethics 30(5) (June 2020)
terms of managing the spread of the virus but also interms of how to deal with the increasing number ofdeaths. Even those whose business is about managing
corpses such as morgues, crematoria, cemeteries andfuneral homes have been caught off guard with thesituations. While funeral directors and others in thedeath care industry are changing the way they care forthe dead, this pandemic reminds them of the challenges
ahead (Kohn & Gould, 2020).
For example, in Italy, people with COVID-19
reportedly “face death alone” as funeral services
suspended, and many dead unburied and uncremated,while in Iran, trenches are being excavated for mass
burials (Kohn & Gould, 2020). On April 1, 2020, Italy
observed a minute of silence to remember their dead due
to Covid-19 (Independent Global News, April 1, 2020). In
Australia, the latest guidelines advise families not to kissthe deceased but they can touch the body if they wash
their hands or use alcohol-based hand sanitizer
immediately afterwards (Kohn & Gould, 2020).
All the guidelines on handling the deceased due to
Covid-19 crafted by different governments throughout
the world are geared towards protecting the living fromthe possibility of getting infected with the virus.
Although different countries have their own cultures andtraditions on how to honor their dead, these cultures andtraditions have not been followed during emergency
situations. This is partly due to what Gaspar (2014) calls
as the “age of secularism” that occupies the minds ofmodern and post-modern people most especially in thehighly urban-based Americans and Europeans. This
scenario poses lots of challenges among countries thathave rich cultural practices, traditions and many rituals
in dealing with their dead. For instance, in thePhilippines, this challenge is very obvious not only
during this Covid-19 pandemic but even during megadisaster such as in Typhoon Yolanda and other disasters
that hit the country, causing the death of many people.
Two Perspectives in Dealing with Dead Bodies in thePhilippines
In the works of Gaspar (2014) among the Yolanda
survivors, he found out that there are two layers ofperspectives in dealing with the dead bodies. Gaspar said
that these two perspectives followed two parallel lines
and each with their own way of dealing with the extreme
circumstances at hand. On the one hand, there is theperspective from the ordinary folks in terms of honoring
the dead in the best way possible as dictated by theircultural traditions and belief system. On the other hand,
there is the perspective from modernity which pushes
the residue of the indigenous belief system and has madethe people very rationale in dealing with their dead(Gaspar, 2014: 67-77).
In the first perspective we can see elaborate rites andrituals such as dances, community gatherings, and others
among the different indigenous tribes in the country
from North to South in honoring their dead. Althoughmany of these tribes have been converted to Christianity
during the Spanish colonization, these rituals are still
alive. In fact, when the Spaniards brought the Catholic
rituals of dealing with the dead, the Filipinos adopted
them because these rituals juxtaposed easily with thelegacy of their pre-conquest ancestors (Gaspar, 2014).
Thus, today many Filipinos continue to practice their239

indigenous cultures and traditions of honoring theirdead which interfaced with Catholic liturgical rites andother elaborate rituals. Even in some elite and middle
class families in the urban centers, we can observe inmany funeral parlors that these rituals persist. Much
more in rural areas, we can see that these rituals ofhonoring the dead are longer and more elaborate.
All these rituals have spiritual dimensions as thecommunity prays for the dead and for the living to beable to have the grace to deal with their grief. Hence, for
the Filipinos, the death of family members or loved ones
is a community affair and everyone in the community,
most especially the members of the immediate family
and the relatives, would do everything they could, when
given the chance, to provide and go through the different
rites and rituals despite horrible circumstances such as
disasters and pandemic. Thus, the different guidelines indealing with dead bodies during this pandemic which
prohibit them to come closer to express their emotionsof gratitude and to say sorry as they pay their lastrespects to their dead brought them not only trauma andanger about but also guilt.
In the second perspective, Gaspar (2014) says that
capitalism mindset and the secular way of dealing withthe dead paved the way for business of corpse
management in funeral parlors to thrive. To earn more
profits, managers have to be engaged in systematic andstrategic planning and management with clear defined
objectives that are stretched to their optimum level(Gaspar, 2014; Kohn & Gould, 2020). It is also evident inthis perspective that democracy would have the Church
and the state separated and focused in their own
business. Humanitarian agencies sprouted to make surerights are respected and human material needs are
responded in a global scale (Gaspar, 2014).
But what about the rights of the people to exercise
their religious beliefs and rituals in dealing with theirdead? Unfortunately, during Covid-19 pandemic, one of
the rights violated was the religious rights of the citizens.
The modern and post modern period put religion at thesideline as secular institutions asserted theirprominence. These secular institutions coopted what
was once the domain of religious and faith institutions
trying to make the latter insignificant in the lives ofpeople (Gaspar, 2014: 78). However, the values of themodern and postmodern era, while appealing and valid,cannot really provide answers to the deepest longingsand yearnings of man. Since man is not only a body but
also a spirit as asserted by Gabriel Marcel and someother philosophers and theologians, there is anexistential ache or angst that permeates every humanspirit. There is always kind of restlessness, anxiety,dread and sense of aloneness that accompany man in his
sojourn here on earth towards his eternal destiny (Sartre,
1989; Rupp, 1988).
Dealing with Existential Aches and Moments of Lossduring Covid-19 Pandemic
In one of our discussions with my students in my
Theology courses we were dealing with the different
inadequate images of God that many people embrace intheir lives. One of the inadequate images of God thatstirred debate among my students is the image that “Godis a tester”. While a lot of theologians would assert that
“God is a tester” image is inadequate and would even

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

provide good theological arguments against it, there arestill people who cling to this image because this image
has helped them in dealing with many adversities in life.
In fact, one of my students shared her difficult struggles
with her family and how she keeps her sanity by
believing that she was like the modern Job who wastested by God during his time but still chose to trust in
Him and in the end, all his blessing and fortunes were
restored by God (See, The book of Job in the Christian
Bible). One student also shared that by believing that
God is just testing him through the many difficulties thatthey have encountered in life made him endure the pains
and the trials thinking that at the end of the test, those
who perform better will have the reward from God.
These are examples of a culture and a belief system that
helped the people cope up with the many difficulties
they have encountered.
In my works as a counselor and spiritual director, Ialso encountered a lot of people who got angry with God,
questioning his love and even power because of theirdifficult experiences, mostly involving death of family
members and loved ones. While most of them would tellme how sorry they are for having that feeling and notion
about God after our conversation, I assured them that
their feelings and thinking about God are normal andeven the “best” response that they could have given
those terrible experiences.
Anger is one of the stages of grieving in Elizabeth
Kubler-Ross’ “On Death and Dying”. According to KublerRoss (1969), anger is not only a normal feeling after anexperience of loss but it is also a necessary stage of thehealing process. While anger is a natural and normal
feeling for a person who experiences abandonment andbeing deserted, our society fears and despises anger.
Thus, even if it can be a strong anchor to give person
temporary stability while he is in the abyss ofnothingness and helplessness, it is not always welcome.
Hence, most often, anger is being suppressed. Althoughpeople do not have to experience the five stages that
Kubler-Ross outlined in her book such as Denial, Anger,
Bargaining, Depression and Acceptance as these are nothierarchical or linear stages, those who experienced
anger have the strength to bind themselves back toreality after being detached from it because of grief(Gregory, 2020).
Normally, their anger is directed towards God, otherpeople and even themselves. Thus, their anger toward
somebody may bring them once more to his social reality
and connect them to people again. Sometimes, theirquestioning about God is an indicator of their strong
faith in God. I reassured my students and those whocome to me for counseling or spiritual direction that
their feeling of anger is normal. I even reminded them of
the importance of it in the process of healing.
For Joyce Rupp, this existential ache is within us
because we are composed of both physical and spiritual
dimensions (Rupp, 1988). Since we are not only
composed of body but also of spirit, our final home is nothere on earth but somewhere beyond this physicalreality. Thus no matter how “good” and “comfortable”
this earth maybe for us, there is always part of us that isyearning and longing for the true homeland where life is
no longer difficult or unfair (Rupp, 1988:24). Thisimplies the importance of self-awareness to be able toget in touch with our deepest longing and yearning.
But what about those who are not gifted with thecapacity for self-introspection? What about those who
refuse to journey deep inside and instead choose toignore and push away these feelings? People cannot
endure ignoring their feelings and keep their sanity for
longer periods of time. In fact, Rupp theorizes that ourloneliness paradoxically connects us with others in theirown aloneness (Rupp, 1988). Our awareness of ourconnectedness with other human beings even in our own
moments of aloneness can be a source of deep
realization that we have companions in our journey
towards completion. This will in turn inspire us to loveourselves with all our imperfections and incompleteness.
This is the true essence of our spirituality. According toKenneth Leech,“True self love means not trying to escape fromourselves, but listening to the voices within us…thisinvolves the acceptance of our fundamental aloneness,
not seeking to reduce it, not hoping that friendship,
marriage, community, or group, will take it away. Thataloneness is an integral part of being human, and an
essential element of love. It is out of that aloneness thatit becomes possible to respond rather than merely react
to people and needs. Response has to grow and emergeout of the depths of myself: it is my response, born out of
my inner struggle and inner self-knowledge, out of myspirit, my deepest core. This is what spirituality is about”(Leech, 1980:44).
The goal of our pilgrimage is simply to keep moving
spiritually little by little everyday. In seeing life as apilgrimage, the vision that is spirituality’s openendedness recognizes that it is not how far one has comethat is significant, but how far one has yet to go (Kurtz &Ketcham, 199: 138). Hence, despite the different aches
that we have because of a tragic event that we
encountered especially during this pandemic situation,
we are challenged to go on even if the going may getrougher and rougher along the way.
Life is still uncertain. Even if lockdown and Enhanced
Community Quarantine will be lifted, we cannot go backto what we have been used to before this pandemic. In
fact, for those who had lost their family members, loved
ones and friends because of the novel corona virus, theirlives will never be as “normal” as before. We areconfronted again and again with the truth that our world
and our life is fragile. Frederick Buechner says, there is
no doubt that the world is fragile and the return of chaos
is a perpetual possibility (Buechner, 2003).
Where do we go from here?
I think it is important that we will now fix our gazeon our God who also suffers but deeply cares for all of us.
This is not saying that we will not do our part. Of course,
we still need to look for solutions (vaccine and others)
for this pandemic. We still need to work so hard to
restore our economy. We will continue to enhance ourknowledge in science and technology, development
theories and economics. But let us not forget to also
focus our attention to the God who cares.
When we experience lots of losses and goodbyes, wecome face to face with the reality of suffering and pain.
But we also come face to face with a God who suffers
pains and hurts with us (Rupp, 1988). This suffering God

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
is personalized in the person of Jesus Christ who
suffered a horrible death on the cross to show to theworld how to live in love in the midst of pains, sufferings,
betrayals and even hatreds. God allowed His Son, Jesus
Christ to have a “full participation in the humancondition just as all of us have to enter fully into it”(Rupp, 1988:39). But God does not orchestrate pains andsufferings in the world. He just allows sufferings tohappen in order for us to experience the fullness of ourhumanity. As Kushner puts it succinctly, God allows
suffering to happen because to block it would mean
blocking also the growth of our human nature (Kushner,1981).
As a caring God, He promised to be with us, tocomfort us, to sustain us and to keep us from being
shattered by our trauma, fear, guilt, sufferings anddifficulties brought about by this pandemic (See, Is. 43:
1-5; 2 Cor 4: 7-18; Rom 8:35-39). God’s compassion andcare is shown in His being a good shepherd to His flock(See, Is. 40:11). According to Joyce Rupp, God’s love issuch a powerful companion for us that no matter how
searing or how intense the hurt of our losses, He will
help us to recover our hope, our courage and our
direction in life (Rupp, 1988: 41). Believing in thisbeautiful promise of God, we will be more discerning to
the will of God in our lives during and after thispandemic. Instead of declaring anything or everything tobe the will of God, we are invited to be more willing to
ask ourselves where in the midst of our pains andsufferings we can discern the loving presence of God(McNeill, Morrison, & Nouwen, 1982: 40).
Aside from understanding and believing that God isalways with us in our moments of pains and sufferings
especially during this pandemic, it is also important to
get in touch with our own philosophies of life. Joyce
Rupp calls these as our “one-liners” or the beliefs andsayings that we have which sum up our vision andphilosophy of life (Rupp, 1988). Some examples of thesecommon sayings and philosophies are: “Nothing ispermanent including pains and sufferings”, “This, too,shall pass”, “God is above all these”, “God will provide”,“If it’s not yet our time, it won’t come to us”, “Life is
beautiful”, “We are blessed and we can be a blessing too”,“There is beauty in the mess”, common among many
Filipinos is “laban lang” (just continue the fight) andthere are lots out there. You discover them when you
talk to many people in your community especially those
who experienced a lot in life.
These “one-liners” helped them cope up with theirtrauma, pains and sufferings. In my experience ofjourneying with people, I discovered that they haveplenty of inner strengths to endure life’s trials andtribulations. These inner strengths gave them the many
“whys” to go on living. These many “whys” to live arewhat Victor Frankl calls in his “Man’s Search for
Meaning”, as the people’s constant search for life’s
meaning and purpose especially in moments of pains
and sufferings (Frankl, 1977). According to Victor
Frankl,“When a man finds that it is his destiny to suffer, he will
have to accept that suffering as his task; the single
unique task. He will have to acknowledge the fact thateven in suffering he is unique and alone in the universe.
No one can relieve him of the suffering or suffer in his

241place. His unique opportunity lies in the way in which hebears his burden” (Frankl, 1977: 123-124).
Victor Frankl’s persistent search for meaning helped
him to survive the difficult moments that he experienced
in life being a prisoner in a concentration camp during
World War II. Instead of succumbing to pain anddepression, he searched for life’s meaning and purpose
through his suffering. Not only was he able to survive thetrials, he even developed a deeper understanding of thehuman spirit and was able to develop his philosophy,
write a book about it which is still very much useful until
today. For Frankl, this will to meaning is man’s vocationthat must be fulfilled by him alone (Frankl, 1977). This
will to meaning defies all dangers and all the despair that
we face in life (Maboloc, 2012:119). This means that man
if man has will to meaning, he has to rise above his pains,
sufferings and circumstances. As counselors, we used his
logotherapy (meaning making) to guide our clients findmeaning in all their experiences and circumstances. Thismeans that the person must hold on to his purpose in life
since living a life without purpose is not living a truly
human life (Maboloc, 2012). Thus, despite pains,
sufferings and difficulties, man should continue to search
for meaning and his purpose for living. Indeed, sufferingand pains are part of man’s existence.
According to Joyce Rupp, sufferings and the “painful
feelings that accompany our experiences of loss are on
all levels of our being – physical, emotional, mental or
spiritual” (Rupp, 1988: 33). We can expect to feel sad,shock, angry or guilty of something we have not done ornot said. We might even have resentment and self-pity.
We might lost our enthusiasm and energy to do our tasks.
Indeed, it is hard to go on believing in a God who cares
when something or someone that we hold so dearly is
being taken away from us. Hence, we are also invited tolearn from the examples of Jesus who embraced his
suffering. It is what we do with our suffering and pains
that matters. Jesus invites those who suffer to think of
their suffering as a source of spiritual growth andblessing. In his teaching, Jesus says,“I tell you solemnly, unless a grain of wheat falls into theground and dies, it will remain a grain, but if it dies, itwill bear much fruit.” (Jn. 12:24)“Blessed are they who mourn for they will be comforted.
Blessed are the meek for they inherit the land.” (Mt. 5:45)
Indeed, there is value in suffering, pain and grief. They
remind us of our incompleteness but they can also lead
us to discover our vast reservoirs of resiliency, vitality
and endurance (Rupp, 1988:57). Suffering or pain can bea refining of purifying element. Suffering, pain and grief
may refine not only our body but also our spirit. Taken
into its proper context and purpose, suffering can bringus to new life.
In the first letter of James in the Christian Bible, ittalks about the value of sufferings, trials and tribulations.
“Consider it all joy, my brothers, when you encounter
various trials for you know that the testing of your faith
produces perseverance. And let perseverance be perfect,
so that you may be perfect and complete, lacking innothing. But if any of you lacks wisdom, he should ask
God who gives all generously and ungrudgingly, and hewill be given. But he should ask in faith, not doubting, for242

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

the one who doubts is like a wave of the sea that isdriven and tossed about by the wind.” (James 1:2-7).
When our suffering transforms us positively we can be asource of positive transformation to others. We are canbe like the bread that is broken, yet blessed and ready to
be distributed to those in need. We are challenged toembrace an attitude of faithful surrender during time oflosses and goodbyes especially in these moments ofcrisis brought about my Covid-19 pandemic. We arereminded to always have hope that what we suffer inthis life (goodbyes, losses, pains, trauma and grief)
cannot be compared to the eternal glory (hello) thatawaits us. (See, Rom 1: 8-18).
Conclusion
In this difficult moment of our lives due to Covid-19
pandemic, our choices mater a lot. These will shape ourlives not only in the present scenario but also in the
future. We have a choice either to wallow in pain, grief
and depression or we choose to go on living and loving
despite hardships, loss and uncertainties in the future.
We will probably experience many losses (life,
properties, jobs, health, etc) but if we still have purposeand meaning in our lives, we will continue to face themany forms of deaths that this pandemic has brought
and might still bring into our lives. Our culture,spirituality, philosophy, faith and belief systems have
many things to offer to us to help us face and embracedifferent kinds of deaths. We can also learn from thedifferent insights of philosophers, theologians, psychotherapists on how to manage trauma and grief. The
teachings and examples of Jesus Christ who experienced
lots of goodbyes and sufferings and how he faced all ofthem can also be an important source of inspiration for
us in dealing our own experiences of pains, sufferingsand goodbyes.
It is then important for the government and thoseworking for the victims of this pandemic to dialogue withthe culture, philosophy, faith and belief systems of thelocal people especially during moments of deaths andmanagement of dead bodies because this will help themto say goodbye to their loss and to strengthen them intheir journey with its own experiences of goodbyes andto prepare them to say hello to a “new life” after thispandemic.
References

Buechner, F. (2003). “Walking in the World with a Fragile God”,
in Walking with God in a Fragile World, Roman and Littlefield
Publishers, Inc., Maryland, USA, edited by James Langfordand Leroy S. Rouner.
Frankl, V. (1977). Man’s Search for Meaning, New York: Pocket
Books Press.
Gaspar, K. (2014). Desperately Seeking God’s Saving Action:
Yolanda Survivors’ Hope Beyond Heartbreaking Lamentations.
Institute of Spirituality in Asia (ISA)
Gregory, C. (2020). “The Five Stages of Grief: An Examination of
the Kubler-Ross Model”, accessed last April 22, 2020 athttps://www.psycom.net/depression.central.grief.html
Kohn, T., & Gould, S. (2020). “Commentary: Funeral homes andmorgues face challenges as coronavirus death toll rises”,
accessed
last
April
23,
2020
at
https://www.channelnewsasia.com/news/commentary/cor
onavirus-covid-19-funeral-wake-quarantine-dead-infectrisk-12579336?cid=h3_referral_inarticlelinks_24082018_cna

Kubler-Ross, E. (1969). On Death and Dying, New York:
Macmillan.
Kushner, H. (1981). When Bad Things Happen to Good People,
New York: Avon Books)
Kurtz, E., & Ketcham, K. (1992). The Spirituality of Imperfection:
Story Telling and the Journey to Wholeness, Bantam Books,
New York, USA.
LaMotte, S. (2020). “Grief and Fear After Covid-19 Death:Managing A Double Trauma”, accessed last April 23, 2020 athttps://cnnphilippines.com/world/2020/4/2/grief-losscoronavirus.html
Maboloc, C.R. (2012). The Pursuit of Being Human: An
Introduction to Philosophy, SMKC Printshoppe, Davao City,
Philippines.
McNeill, D., Morrison, D.;, & Nouwen, H. (1982). Compassion,
Garden City, New York, Doubleday and Co., Inc.)
Rupp, J. (1988). Praying our Goodbyes. Ave Maria Press.
Sartre, Jean Paul. (1989). Existentialism and Humanism, London,
Methuen Press.

Nursing in Pakistan: issues and challenges-Sumaira Khowaja-Punjwani, PhD (USA), CPB (USA), MBeth(Pak) & BScN (Pak)
Founding Principal & Associate Professor, Saifee Burhani
School of Nursing, Saifee Hospital Trust, ST-1, Block F, North
Nazimabad, Karachi-74700, Pakistan; Visiting Professor of
Bioethics & Nursing, American Univ. Sovereign Nations, USA
Email: sumaira.khowaja@yahoo.com,
skpunjwani@sbson.edu.pk

Abstract
Nursing staff are considered as the backbone ofcontemporary, high quality healthcare systems aroundthe globe, where standards of health care performanceand provision are determined by the knowledge andskills of nurses.
This paper evolved out of a PhD Dissertation titled“Past, Present and Future Trends of Nursing Workforce
Migration: Analysis and Policy Implications”. This article
provides an overview about nursing in healthcaredelivery system of Pakistan and talks about Nursing inPakistan. This article illustrates history of nursing inPakistan, regulation of nursing in Pakistan including
details regarding national regulatory bodies, provincial
regulatory bodies and role of nursing federations andunions. It also discusses in detail nursing education
system in Pakistan, status and image of nursing inPakistan, the importance of nursing workforce inhealthcare, nurse employment in healthcare hierarchy inPakistan including power as nurse in current system andworking conditions of nurses in Pakistan, shortage ofnursing in Pakistan as a reason of demand and supply
gap and migration of Pakistani educated nurses toforeign countries highlighting reasons for nurse
migration.
History of nursing in Pakistan
The history of nursing in Pakistan is deep-rooted in the
pre-partition period starting from 1931 to 1941. There ishardly any document that provides a comprehensive
picture of History of Nursing in Pakistan except amaster’s thesis dissertation which was written by Ms.
Hafiza Hemani in 1996. As per Hemani (1996), in 1860
Florence Nightingale established school of nursing inEubios Journal of Asian and International Bioethics 30(5) (June 2020)
London in association with St. Thomas’s Hospital which
offered first formal educational program to prepare
students as nurses. In the same year an initiative wastaken by Government of the Indian subcontinent fortraining of midwives.
Nursing in Indo-Pak region originated in 1884, when
Anglo-Indian sisters came to India and promoted theprofession of nursing. Also, the first school of nursing
was opened at Mayo Hospital Lahore where mostly
nurses were coming from England to work, because
Muslim and Hindu girls were not joining nursing due totheir cultural values. Even the ones who were joining theprofession belonged to low socio-economic backgroundand were converting from Hinduism to Christian. Mostly,schools were attached to Mission Hospitals and all the
Matrons/ Nursing Superintendents were Anglo Nurses.
In 1871, another school was opened in Northern India.
From 1907 to 1941, great number of Nursing
Superintendents were hired from Europe in India who
developed rules, standards and curriculum outline forthe first time for Indo-Pak Missionary Hospitals and also
opened nursing schools in all provinces of India andPakistan. Those rules, standards and curriculum werelater adopted by civil hospitals.
In 1947 after partition, British nurses and nonMuslim nurses left Pakistan and there was a huge gap innursing services as insignificant number of nurses wereavailable to care for refugees wounded in riots. At thattime, eminent political female leaders of West-Pakistan
Ms. Fatima Jinnah and Rana Begum Liaquat Ali Khan who
was a midwife called out women to come out of theirhomes to serve the refugees in camps. Those women’s
were working under supervision of few trained nurses
available. Initially, 2 weeks training program wasdesigned to prepare Nursing Assistants and entry into
this program was after 8th grade. In 1948, two nursing
schools were opened i.e. Ganga Ram Hospital in Lahore
and Jinnah Postgraduate Medical College (JPMC) Karachi
followed by development of nursing schools in
Bahawalpur, Hyderabad, Multan, Lady Reading Hospital
Peshawar, Civil Hospital Karachi and Mayo Clinic Lahore.
In 1949, the Central Council of Nursing (CCN) for
Pakistan was established comprising 33 members
including 9 nurses, 3 midwives and LHV and doctors andeducators. The goal of CCN was to establish uniform
standards for training and certificate throughout country.
In 1950, CCN passed the rule to have two grades ofnurses’ i.e. General Nurse; training of 3 years and 3
months and Nursing Assistant. Girls with minimum 17
years of age were deemed admissible for nursing andpreference was given to unmarried, widowed, divorced
or childless women. For Females, Grade 8 education andability to read and write English was the pre-requisite foradmission as General Nurse and for Nursing Assistantability to read and write Urdu was the only requisite. For
Male, matriculation was must for entry into General
Nursing however, they were not allowed to haveenrollment in Nursing Assistant program. There were no
fixed dates for admission rather intake was done roundthe year in order to minimize shortage of nurses andthere were no separate classes for first, second and thirdyear students respectively.
In 1952, the Pakistan Nursing Council (PNC) wasestablished and admissions were opened biannually i.e.

243

April and November and Matric was must for females
instead of grade 8 for General Nursing whereas, grade 8
was must for admission in to midwifery program insteadof ability to read and write Urdu. These developments
were later followed by establishment of examination
boards and addition of courses in curriculum in 1973. It
was made mandatory for a nursing institute to obtainrecognition from PNC and follow prescribed curriculumand standards set by PNC. In 1973, National Assembly of
Pakistan passed act to formulate Provincial Nursing
Examination Board under Pakistan Nursing Council Act
No. XXVI of 1973 after which four Provincial Nursing
Examination Board were formulated i.e. Punjab Nurses
Examination Board (PNEB), Khyber Pakhtunkhwa
Nurses Examination Board (KPKNEB), Sindh Nurses
Examination Board (SNEB) and Baluchistan Nurses
Examination Board (BNEB) for the province of Punjab,
Khyber
Pakhtunkhwa,
Sindh
and
Baluchistan
respectively (Pakistan Nursing Council, n.d.; Sindh
Nurses Examination Board, 2017). In 1988, 2 year Post
Registered Nurse Bachelors of Science in Nursing (Post
RN BScN) Program was introduced for nurses who had
obtained Diploma in General Nursing and wanted to opt
for degree program in Nursing. In 1997, four year
Bachelors of Science in Nursing (BScN) degree program
was initiated in which the pre-requisite for admission isIntermediate. In 2001, 2 year Masters of Science inNursing (MScN) program was started and just recently
i.e. in 2014, PhD in Nursing program has beencommenced in Pakistan (The Aga Khan University, 2017).
Regulation of nursing in Pakistan
National regulatory bodies: Pakistan Nursing Council(PNC) is an autonomous regulatory body constituted
under the Pakistan Nursing Council Act 1952 & 1973.
PNC is the national regulatory body that is empowered toregister and license nurses, midwives, lady healthvisitors and nursing auxiliaries; sets the curriculum fornurses; provides approval to nursing education
institutions and programs; and works closely with four
provincial nursing examination boards. PNC wasestablished in 1948 (Pakistan Nursing Council, n.d.).
Provincial regulatory bodies: Under the umbrella ofPakistan Nursing Council (PNC), four Nursing
Examination Board are working i.e. Punjab Nurses
Examination Board (PNEB), Khyber Pakhtunkhwa
Nurses Examination Board (KPKNEB), Sindh Nurses
Examination Board (SNEB) and Baluchistan Nurses
Examination Board (BNEB) for the province of Punjab,
Khyber
Pakhtunkhwa,
Sindh
and
Baluchistan
respectively (Pakistan Nursing Council, n.d.). The role ofthese examination boards is to conduct examinations
and declare results for all categories of diploma program
Nurses/Midwives/LHVs and organize workshops for
examiners/teachers of nursing schools to update systemof examination under the guidance of Pakistan Nursing
Council and its reporting in the Pakistan Nursing Council
meeting (Sindh Nurses Examination Board, 2017).
Role of nursing federations and unions: Competing
unions focus on collective bargaining as they can exert
significant influence in negotiation of working
conditions, development of private nursing schools and244

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)degree programs, and development of the profession(Aluwihare-Samaranayake, 2017). There are numerous
Nursing Federations and Unions currently operating inPakistan including, Pakistan Nursing Federation (PNF)
which is an independent non-governmental professional
association of nursing in Pakistan which was registeredin 1972, Young Nurses Associations with respective
provincial young nurses association like Sindh Young
Nurses Association (SYNA) and etc.
Nursing education system in Pakistan: In Pakistan,Nursing education system can be categorized in to threecadres, i.e. general nursing, midwifery and public healthnursing. Since the beginning of Nursing profession in
Pakistan till today the predominant mode of nursing
education in public as well as private sector is Diploma in
General Nursing (RN) program which comprise three
years of education after matriculation (Gul, 2008).
However, as per the directives of Pakistan Nursing
Council (PNC) and Higher Education Commission of
Pakistan (HEC), in 2019 the transition from Diploma in
General Nursing program to four years Bachelors of
Science in Nursing (Generic BScN) program is inprogress and many colleges are now phasing off RN
program and instead are offering Generic BScN programin which the pre-requite for entry is intermediate (FSc)
premedical. Diploma in Midwifery was initially one yearof training program after matriculation; however,currently three programs in Midwifery are offered i.e. 15
months Diploma in Pupil Midwifery and 18 months
Diploma in Community Midwifery in which pre-requisite
for admission is matriculation, and 1 year Diploma in
Nurse Midwifery which is offered to candidates who havecompleted 3 years Diploma in General Nursing (RN). Few
schools are planning to introduce 4 years Bachelors of
Science in Midwifery (BScM) program in which a
candidate can get enrollment after completion ofintermediate. Public Health Nursing cadre includes 16months Lady Health Visitor (LHV) program. For postbasic nursing education, 1 year specialization programsin almost 22 practice strands, 2 year Post Registered
Nurse Bachelor of Science in Nursing (Post RN BScN) andtwo year Post Registered Nurse Bachelor of Science inMidwifery (Post RN BScM) program for which the prerequisite is Diploma in General Nursing (RN) and
Diploma in Midwifery (RM) with two years of clinicalexperience are being offered. Post RN BScN and Post RN
BScM are equivalent to 16 years of education as per HEC.
For post graduate education in Nursing, 2 year Mastersof Science in Nursing (MScN) program is offered by few
universities whereas, PhD program in Nursing has been
recently started by one university only.
Nursing schools are usually working under theauthority of hospital administration and some nursing
schools have separate principal for the school with
reporting relationship to hospital administrator who
usually is a doctor by profession (Gul, 2008). Although,Pakistan Nursing Council (PNC) has repeatedly released
notifications that only nursing professionals can head theschool with most recent notification being issued in 2017nevertheless, to date many schools are unable to fulfill
this very essential requirement.
Referring to apprenticeship system of training,
students gain experience by working in hospital clinicalsettings, though many times unsupervised by qualified
faculty and staff due to their scarcity; therefore, it is not
unusual to find nursing students working independently
without supervision especially during evening and night
shift (Gul, 2008).
Curriculum is fundamental to nursing education forpatient safety, cultural competence and evidenced based
practice by use of technology and informatics, interprofessional education, application of new pedagogies,
critical thinking and simulation. The national curriculumfor RM, RN and LHV program exists and is implemented
widely. The national curriculum for BScN program wasset by Higher Education Commission (HEC) with thecooperation of Pakistan Nursing Council (PNC) in 2006
for the first time which has later been revised in 2011
which includes all the essential elements and trends ofmodern education (Khan, Ghani, & Badsha, 2015). PNC is
working for the development of a uniform Masters of
Science in Nursing curriculum and revision of Post RN
BScN curriculum. Nursing examination for diploma
programs are conducted by respective provincial nursing
examination boards whereas, medical universities
conduct examinations for degree programs.
Status and image of nursing in Pakistan
Image is defined as the “character of a thing or person as
perceived by public” and Kalisch and Kalisch as cited byGul (2008) defined nursing image as “the sum of beliefs,
ideas, and impressions that people have of nurses andnursing”. The image and status of nursing is a global
problem that nurses face and literature suggests several
reasons that has contributed in shaping poor image ofnursing which includes; role of nurse is not clearly
understood by general public, lack of recognition fromother health professionals, low wages, compromised
working conditions, unsafe work environment, andnegative portrayal of nurses in media for instance as
handmaidens to physicians, or sex objects (Gul, 2008).
Several studies has been done to explore status andimage of nursing in Pakistan and many studies has
concluded that the image of nursing in Pakistan isgenerally poor since its inception and over the period oftime this has remained unchanged. This poor image ofnursing gives a setback for nursing to advanceprofessionally and is also one of the contributing factor
for shortage of nurses as the new generation does notchoose the profession as priority (Gulzar, et al., 2016).
Importance of nursing workforce in healthcare
Nursing staff are considered as the backbone ofcontemporary, high quality healthcare systems aroundthe globe, where standards of health care performanceand provision are determined by the knowledge andskills of nurses. In today’s world, the role of nurses is not
only confined to clinical care in hospital settings, rather
their role has been extended to advanced practice arenas
as they act as counselors, provides risk-manage
challenging behaviors and promote healthy and safe
living in community (Muhammad, 2015). Moreover,nurses with advance qualifications work as senior
executives in hospitals, long term care facilities,
community health centers, home care agencies, nursing
colleges and professional associations (Bernard, 2014).
Their role in administrative position includes managing

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
large number of staff and multi-million dollar budgets,
establishing standards for care by developing Standard
Operating Procedures and Policies (SOPs) at clinicaland/or public health level. ‘There is no denying in thefact that nurses play a major role in delivering healthcare services. Their round-the-clock presence,
observation skills and vigilance allows doctors to makebetter diagnoses and propose better treatments. They
provide care and assist in cure, participate inrehabilitation of the patients, and provide support to thehealthcare providers’ (Khan, Ghani, & Badsha, 2015)
which no other healthcare professional can.
Literature has suggested improved patient outcomes
and decrease morbidity and mortality where nurse topatient ratio is higher (Aiken, Sloane, Lake, Sochalski, &Weber, 1999; Aiken, Clarke, & Sloane, Hospital staffing,organization, and quality of care: Cross-national findings,
2002; Zhu, et al., 2012). In addition, adequate nurse
patient ratio have positive impact on staff retention,
increased job satisfaction and reduced staff burnout(Aiken, Sloane, Lake, Sochalski, & Weber, 1999). On thecontrary, inadequate nurse patient ratio results in loss ofimportant aspects of care and negative patient outcomes(Zhu, et al., 2012).
Nurse employment in healthcare hierarchy inPakistan
Healthcare hierarchy
Likewise nursing education, nurse employment inhealthcare hierarchy in Pakistan comprise of three cadre
nursing professionals that are regulated by the Pakistan
Nursing Council (PNC) as Registered Nurses (RNs),
Registered Midwifes (RMs) and Lady Health Visitors(LHVs). RNs mainly work in hospital settings, whereas
LHVs and midwives have predominant role incommunity setting for maternal and child care. In
general, midwives and LHVs are paid less than nurses
however, they can have their private practice and canearn more money than nurses. As they are moreautonomous in their practice therefore are wellrespected like doctors. Nurses having post-graduation
qualification can work in administrative and teachingcapacity in hospitals and nursing schools (Gul, 2008).
Although, bedside nurses salaries are better than nurses
working at academic positions yet bedside nursing is
considered less attractive due to challenging work
conditions.
Because the health system of Pakistan includes boththe public and private sector therefore, nurses have
employment opportunities in both sectors. In
government hospitals, there is lack of appropriate
service structure because of which a nurse employed onthe ‘Basic Pay Scale (BPS)’ has to continue on the same
grade for their entire tenure (Muhammad, 2015).
Additionally, nurses encounters low wages and highworkload, and lack of system for protection of nurses’
right. However, the advantage of working in public sector
hospitals include long-term employment benefit as thereis less chance of the job being terminated. Private sector
organizations pay better salaries and benefits to nurses
though, mostly nurses are hired on contractual positions
therefore job security is a great concern.

245Power as nurse in current system
Nurses in Pakistan tend to be relatively powerless,perhaps because of social position, knowledge deficits,
attitudinal beliefs and perceived burden of work (Gulzar,
et al., 2016). Poor management and infrastructure, low
wages, lack of recognition of the value of nursing as
profession, scarce resources in education as well as
clinical settings, medical dominance and limited
opportunity for career progression and involvement instrategic planning for health development act ascontributing factors for powerlessness and oppression
amongst nurses working in Pakistan which is main
reason that nurses perceive nursing as a job rather thana profession (Lee & Saeed, 2001).
Empowerment to nurses is essential if the status ofnurses working in Pakistan needs raise as powerlessness
leads
to
job
dissatisfaction,
burnout
anddepersonalization and contributes to poor patient
outcomes (Gulzar, et al., 2016). Pakistan has a long
history of severe leadership crises in nursing profession
because of which nurses in Pakistan are rarely preparedto take on the role of decision-maker, risk-taker, teacher,or change-agent (Lee & Saeed, 2001).
Working conditions of nurses in Pakistan
Pakistan is one of the very few countries in the worldthat has an inverse ratio of nurses to doctors at 1:2(Pakistan Bureau of Statistics, 2017), which greatly
affects the role of nurse in healthcare settings. Due tosevere shortage and medical dominance the role ofnurses’ remains very limited and many ordinary nursing
tasks, such as monitoring vital signs and dressing
wounds are performed by doctors, whereas, nurses areprimarily responsible for medication administration,
carrying out doctors’ orders and clerical functions (Gul,2008). For instance, arrangement of linen or soap andwater, trouble shooting for patient complaints related tohousekeeping or maintenance. The current working
conditions of nursing workforce in Pakistan arechallenging which is one of the major factor contributing
to anxiety and depression amongst nurses due to lowlevels of job satisfaction (Khowaja et al., 2005).
Bahalkani et al. (2011) conducted a study at one tertiarycare hospital in Islamabad and found 86% of Pakistaninurses were not satisfied, and 26% were highly
dissatisfied, with their working lives. Poor working
environment, low salaries with no or poor fringe
benefits, dignity, lack of training opportunities,
inadequate supervision, responsibility given at
workplace and time pressure were the major reasons of
dissatisfaction (Bahalkani, et al., 2011). It is therefore,
important to critically explore the context of living andworking conditions for nurses in Pakistan.
Shortage of nursing in Pakistan
Poor management and planning: In Pakistan,government has paid little attention for development of astrategy for nursing workforce planning andmanagement. This has resulted in a very low nurse topatient ratio. In this context, migration of Pakistani
educated nurses to foreign countries has negative effecton an already weak healthcare system.

246

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

Table 1: PNC Recognized Institutes Summary
Program
PunjabEntry Program
RN
RM
CMW
PM
LHV
LPN
FWW
Generic BScN
Total with respect to provinceand sanctioned seats

Province with sanctioned seats
Sindh
KPK
Balochistan

Total withrespect toprogram

58(5237)
60(1811)
50(1734)
20(320)
14(1291)
12
(355)
3
(95)
15
(535)

58
(3083)
29(1070)
47(1443)
11
(230)
6
(245)
4
(105)
2
(50)
12
(605)

14
(1355)
12
(255)
15
(706)
-

8
(275)
5
(60)
17
(533)
-

138 (9950)

9
(365)
2
(45)
2
(65)
6
(210)

6
(185)
-

35 (2086)

1
(30)
2
(45)

8 (240)232(11378)169(6831)

60(3001)

39(1128)

500(22338)

13

24

01

01

39

15
(500)
3
(100)
1
(8)

24
(1005)
1
(50)
3
(70)

6
(180)
1
(30)
-

1
(25)
-

46 (1710)-

4 (78)

32
(608)

52
(1125)

8
(210)

2
(25)

94
(1968)

106 (3196)
129 (4416)
31 (550)

18 (505)35 (1395)

Advance Program
Post Basic Specialty Courses
Post RN BScN
Fast Track BScN
MScN
Total with respect to provinceand sanctioned seats

Subsequently, the decision of Pakistani nurses to work
abroad constitutes a ‘double edged sword’, where
personal development abroad conflicts with thecollective development of healthcare in home country(Gul, 2008). Numerous factors seems to contribute toregional and national shortage of nurses, such as
decreasing trend amongst people to enter in nursing
programs, demand and supply gap of nurses ascomparative to market need, and internal and externalmigration of nurses from disadvantaged areas withincountries or from low and middle income countries tohigh income countries (Aluwihare-Samaranayake, 2017).
The actual number of nurses in Pakistan is unknown
and the estimated numbers usually differs from reality(Gul, 2008) as many nurses who are working in Pakistan
are not registered with Pakistan Nursing Council. As per
Pakistan Bureau of Statistics, Government of Pakistan in2017 there are 103,777 Registered Nurses, 38,060
Registered Midwives and 18,400 Registered Lady Health
Visitors (Pakistan Bureau of Statistics, 2017). As per
Express Tribune 2018, a meeting was held in at the
Ministry of National Health Services Regulations andCoordination (NHSRC) in which NHSRC Federal Minister
Aamir Mehmood Kiyani informed only 5,000 of said

5 (180)nurses hold Bachelor’s degree in Nursing, 190 Master’s
degree and only 9 PhDs in Nursing.
Demand and supply gap
The total number of nursing institutes recognized by
PNC for nursing entry level programs including, RN, RM,
CMW, PM, LHV, LPN, FWW and Generic BScN are 500
with capacity to accommodate 22,338 nursing students
and 94 institutes offer advance level program including 1
year post basic specialty diploma courses, Post RN BScN
Program, Fast Track Post RN BScN Program and MScN
program with sanctioned seats around 1,968 (Refer
Table 1: PNC recognized Institutes Summary) (PNC,
2018). Whereas, as per Ministry of National HealthServices Regulation and Coordination report for Human
Resources for Health Vision 2018 – 30 published on April
2018 mentions that total number of approved nursing
and midwifery institutions in the country are 215 by theend of 2017, out of which 145 are public sector institutes
including Armed Forces institutes and 70 are private
sector including missionary schools which altogether
produce around 9,728 nurses annually as of 2017
(Pakistan Ministry of National Services: Regulations &Coordination, 2018).

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
Considering the population of Pakistan as per
Pakistan Bureau of Statistics 2018, there is 93.41% ofshortfall of nurses and referring to statistics provided intable 06 PNC recognized nursing institutes has capacity
to produce only 22,338 nurses annually and currently is
producing 9,728 nurses annually therefore, it can beconcluded that there is huge gap between demand andsupply of nurses which is one of the significant factor ofshortage of nurses in Pakistan. Additionally, in 2019 PNC
issued a notification as per the directives of HEC in which
admission in Diploma in General Nursing (RN) program
has been closed and now institutes need to develop
capacity for Generic BScN program instead of RN whichmeans that with the closure of RN program the gap isgoing to be more wide because out of 22,338 nurses,
44.5 % (9,950) opt for a RN program for entry in tonursing profession. Although, the initiative to stop RN
program is worthy for future however, it would havebeen appropriate if the measures would have been taken
to develop capacity amongst recognized nursing schools
offering RN program to upgrade themselves for Generic
BScN for smooth transition without inhibiting thenumber of nurses that these institutes prepare annually
to maintain the trained workforce misbalance as far as
the demand and supply of nurses is concerned.
Migration of Pakistani educated nurses to foreigncountries: Migration of Pakistani educated nurses toforeign countries has been taking place since decades
therefore, it is an established phenomenon.
Advertisements regarding job vacancies in Saudi Arabia,
Bharain, Oman, Abu-Dhabi, Kuwait, United Kingdom andother countries appears in newspaper on weekly basis.
There is no absolute data available which depicts thenumber of Pakistani educated nurses that migrateannually however, it is estimated that approximately
15% of nurses from the developing countries including
Pakistan are moving to developed countries every year
(Muhammad, 2015). Developing countries like Pakistan
is the main victim of loss of trained health professionals
because of increase in globalization which has resulted insevere shortage of nurses due to internal migration fromrural to urban areas, and external migration fromdeveloping to developed countries. Significant loss ofhealthcare human resource due to increase migration
trend has compromised the capacity of health systems todeliver care in areas where it is required the most
(Muhammad, 2015)
Reasons for nurse migration: The causes of migration
are numerous and multifaceted, and often are influenced
by both sender and recipient country. As mentioned byKingma (2007) most frequent causes of nurses migration
are wage differences, political unrest, working
conditions, lack of opportunities, possibility for
professional development, active recruitment, better
quality of life and personal safety (Nilsen, 2012). One of
the significant factor that qualifies nurses to migratefrom Pakistan to abroad is their image and status asnurses in society (Hussain & Afzal, 2015). The prodigious
demand for nurses in most developed countries makes
the migration process more efficient as thousands ofnurses migrate each year to obtain labour abroad.
Additionally, lack of incentives and information about247

opportunities at home, non-probability of pensions
hinders nurses to return to their country of origin. On
the contrary, major reasons of nurses to stay and work intheir home country are often based on commitment andmoral, culture, linguistics and good governance (Nilsen,2012).
Conclusion
Nursing in Pakistan is in its infancy and does not yet havethe status of a mainstream profession. The public imageof nursing is poor and the profession faces challenges on
many facades. In Nursing, the ineffective educational
system, stumpy wages and migration of healthcare
workers to developed countries is tallying the workforce
deficiency. Nurses struggle for their voices to hear and toachieve professional status. Lack of political andprofessional power, strategic planning, and humanresource development and monitoring in the healthsector have led to inadequate nurse recruitment andretention, varied educational preparation, anddeficiencies in licensure of the nurse workforce.
However, to meet health demands of the growing
population, Pakistan needs to, both, train and retain
more nurses for future workforce planning.
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Empowering the poor and the front-liners;
equality of capability in the time of COVID19 pandemic-Gerry Arambala
La Salle University-Ozamiz, the Philippines
Email: gerryarambala33@yahoo.com

Abstract
The advent of the equality of capability theory, as
developed by Amartya Sen, has brought about theradicalization of the conventional theories of social
justice and development. Sen’s remarkable contribution
in the field of developmental theories has paved the way
for the reconfiguration and development of normative
economics and political philosophy. With his insistenceon humanizing development and focusing on the actual
freedom of the person as the main criteria fordevelopment, Sen’s capability approach will be utilized
as the moral framework in assessing the government’s
response measures to fight against COVID-19 pandemic.
The global pandemic poses an immediate threat to boththe poorest of the poor communities and to the healthcare sectors of society. Consequently, any response
measure that the government should take must be
directed towards sustaining both the socio-economic
and healthcare objectives. It must help in enabling poor
communities to sustain themselves during the entire
pandemic; more so, it must likewise capacitate andstrengthen the healthcare system in order to provide
better services to the infected and to protect its
healthcare front-liners. The crucial question of equalityof capability among the poor and the front-liners will be
examined by the paper using the capability approach
theory in the context of the global pandemic.
What is equality of capability theory about?
Over the past decades the capability approach received
substantial attention in the field of normative economics
and political philosophy. Its remarkable contribution in
the reconfiguration of developmental studies isexpressed in its being the central paradigm forevaluating developmental projects in the Humandevelopment Report series (HDR) and in the United
Nations Development Program. The capability approach
was also influential in the World Bank’s crafting ofdevelopmental policies during the Wolfensohn era. The
1990 Human Development Report emphatically asserts
that, “Human development is a process of enlarging
people’s choices” (UNDP: Human Development Report,
1990). What this implies is that evaluating humandevelopment should be based on the actual capacity of
the individual to choose from among life’s bestalternatives, and that any constraint that limits the
person from choosing freely what she deemed asreasonable states of beings and doings is a latent
manifestation of injustice and deprivation. Sen simplifies
the point by asserting that “Development, in this view, isthe process of expanding human freedoms, and theassessment of development has to be informed by thisconsideration” (Sen, 199:36). Des Gasper explains that
The Human Development Report’s reformulation of the
1970’s development perspective of the United Nations
Development Program (UNDP) from pure economic
growth of development to expansion of human freedom
suggests that human development, as well-being, is morethan just building human capital to support theeconomic growth (Des Gasper, 2002). Sen argues thatpeoples are not just means for economic development
but are likewise the necessary ends of development(Anand and Sen, 2000). “Economic growth must be seen
as a means towards human development rather thanhuman development as being for economic growth (DesGasper, 2002: 442).” Although there is a necessaryinterrelation between the human capital and economic
structureofdevelopment,
nonetheless,such
interrelation is aimed at humanizing development. The“human” in development is the object of every
developmental project.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
Ingrid Robeyns in the paper “An Unworkable Idea or
a Promising Alternative? Sen’s Capability Approach Reexamined” explained in full length the nature of Sen’s
capability approach under three headings: “1. As aframework of thought; 2. As a critique on otherapproaches to welfare evaluation; 3. As a formula to
make interpersonal comparisons of welfare (Robeyns,
2000: 3).” She argued that in order to better understandthe direction and the structure of the capability
approach it is imperative that it should be examined
under the three aforementioned levels where it isoperating. Equality of capability theory, in this regard, isconceived as a framework of thought that is directed
towards assessing and evaluating social issues such as,
poverty, social injustices, inequality, human well-being,
freedom, liberty, gender biases and social ethics. It
provides for a normative perspective that can be applied
for efficiency evaluation of alternative approaches andconsequently rejects those it considers normatively
insufficient and inadequate (Robeyns, 2000: 4). The
conceptual foundations of the capability approach isgrounded in Sen’s critique to welfare economics, whichconflates ideas of well-being with utility (utilitarianism),
income with development (welfarism) and Rawls’s equal
distribution of the primary social goods as justice anddevelopment. For Sen, all the aforementioned alternative
approaches to development and justice are inefficient toaccount for the actual development and deprivation of
persons. This is so because sheer acquisition andconsumption of goods cannot translate to actual
development owing to the realities of interpersonal
differences. The capability approach argues that theproper space for evaluating individual development is
the space of positive freedom “seen in the form ofindividual capabilities to do things that a person has
reason to value (Sen, 1999: 56).” What this means is thatfor Sen, development should be conceived “in terms of
the expansion of substantive human freedom (Drezel
and Sen, 2002: 3).” This, however, does not mean that
Sen is rejecting the necessary importance of opulence inthe development of the individual; in fact heacknowledges that “Being “well-off” may help, otherthings given, to have “well-being”, but further adds that,“there is a personal quality in the latter absent in theformer (Sen, 1984: 195).”
More so, for Sen commodities and social resources
serve only as means for development and not as ends.
What matters therefore, is that the individual iscapacitated to project for the kinds of functioning (statesof beings and doings) she finds reasonable to be or do.
Being well-off is limited only to the “person’s commandover things outside -including what Rawls calls “primary
goods”. Having “well-being,” on the other hand, is not
something outside her that she commands, butsomething in her that she achieves (Sen, 1984: 195).” Fora poor ambulant vendor who is a father of 4 children andwhose subsistence and the survival of his entire family
defend solely on his everyday income from the goods hesells, 5 kilos of rice, two pieces of cup noodles, two piecesof canned sardines may not necessarily be enough tosustain his family’s well-being during the entire
lockdown. The vendor needs more than just income andcommodities in order for him to secure the life that iswell for his entire family. Furthermore, Sen argues that249

opulence in the form of possession and consumption of
goods is undoubtedly important in enhancing thestandard of living (Sen, 1985). However, he further
asserts that “The standard of living is not a standard ofopulence, even though it is inter alia influenced byopulence. It must be directly a matter of the life one
leads rather than of the resources and means one has tolead a life (Sen, 1985: 16).” What that means is thatdevelopment is a matter of capabilities and functionings
and not directly on the possession and consumption of
resources, which is presupposed in opulence and utility.
Human development in the time of a pandemic
It has been discussed in the above section that humandevelopment must not solely be conceived as purely
economic; rather it must be centered on developing andexpanding human capabilities and functionings. The
need to extend our conventional ideas of developmentfrom purely economic to human well-being is founded in
the presupposition that economic progressions are notends in themselves but are means for human flourishing.
That is, opulence in terms of acquiring and consuming
resources serve as instrument for human development
and cannot account for the totality of actual development
and individual deprivation. Such is the case insofar asincome and commodities cannot explain for the extent of
the sufferings a human being has to hurdle owing to her
actual state of disadvantage. A pregnant woman needs
more than just income for her to flourish in her actual
state of capability deprivation, as compare to a young
lady who is free from any social responsibilities and iswithout impairments. What the pregnant woman needs
is the freedom to choose freely from among life’s choicesthat she finds fitting for her actual state of special need;that opportunities for development be open to her, suchas the most effective healthcare services be given to herduring her pregnancy until her delivery, easy access toeffective medicines that are vital for her state of delicate
well-being and vaccines be available for her child to
support its development, and so on. Many lamented
about the news that for some poor Filipinos having
8000.00 pesos may not still be enough to sustain theirindividual well-being. Some of these people wholamented, may have good reasons to support theirlamentations over the said statement, however, onemust not set aside our individual and interpersonal
differences that significantly affect the person’s capacity
to transform income and resources to actual
development. A poor and sickly old man lying in his bed
inside his dilapidated shanty somewhere in the urban
slums of Manila, is given the same amount (8000.00
pesos) may not achieve the same level of development
satisfaction similar to a healthy man who lives in anapartment and is loved by everybody in the community.
Sen argues that equal income to persons having unequal
needs will not result to equal development.
Moreover, the question of human development isfurther made relevant when is confronted with theprevailing problem of a global pandemic. Over the pastfew months, the world is being afflicted by a highly
infectious disease that has infected 3,073,603 in 210
countries all over the world and has caused the death ofsome 211,768 people. COVID-19 has become a global
nightmare. It has afflicted most of the first world

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countries in the north; USA with its 1.01M cases and56,634 deaths followed by Spain with 209k cases and23,521 deaths and so on, this suggests that the virus
respects no borders and economic status in the global
arena. Everyone can be a victim of the dreadful effects ofthe virus. Nonetheless, the truth remains that the mostvulnerable communities during the time of a pandemic
are the poorest of the poor communities and thedeveloping countries.
According to the World Bank’s latest global poverty
report an estimated 10 percent of the world’s population
or 734 million people live below the international
poverty threshold of USD 1.90 a day. However due to theongoing crisis of the COVID-19 pandemic the World Bank
fears that the five years progress in poverty eradication
will be erased. And some 40 to 60 million people will be
added to the 734 million who are living under theinternational poverty threshold of USD 1.90 a day. The
World Bank reiterated that the pandemic will have adisproportionate effect to the poor, through job loss,
rising prices, scarcity of food supplies, and disruptions offundamental services such as education and health careservice (The World Health Organization, 2020). The
most devastating blow of the pandemic is moreexperienced by the struggling poorer societies than by
the rich communities. The lack of basic resources tosustain the economic and social balance of poorer
countries and the absence of well-established health caresystem during the global health crisis makes thesituation of the poorer communities all the more
deplorable. In addition, most of the poorer societies areoften characterized by poor political governance,
incoherent bureaucracy, corrupt and incompetentleaders, and are suffering from political violence, andfrom diseases related to poverty; all these unfortunate
circumstances inevitably exacerbate the unimaginable
impact of the pandemic to the lives of the global poor.
Reports from the World Vision affirmed that “In the
Middle East and North Africa, the number of people
living in extreme poverty nearly doubled in two years,
from 9.5 million to 18.6 million, mainly due to the crises
in Syria and Yemen (World Vision: Global Poverty Facts,2020).” And further adds that “when looking beyond
income to people experiencing deprivation in health,education, and living standards, 1.3 billion people in 104
developing countries are multidimensionally poor
(World Vision: Global Poverty Facts, 2020).” Poverty is amultidimensional political phenomenon, so that
attempts of eradicating it under one perspective may notnecessarily lead to a positive result. Sen argues thathuman development is all about functioning andcapabilities, rather than just goods and resources. It
speaks ultimately of the freedom to achieve life’s
different functions. In a pandemic any government
response measure must see to it that the overall
development and capacity of the individual member issecured in order to ensure the balance of the economic
and political objectives. Furthermore, inasmuch as
ensuring the positive health of every member forms partof the overall positive freedom of every human being;
health policies must be strengthened and must likewise
be aimed at empowering the people who are in thefrontline by providing them of the necessary facilities,
equipment and technologies needed to properly battle

against the highly infectious disease, and thus provide
quality health care to those stricken by the virus. Moreso, in securing the human capital (empowering thepeople and securing for them their necessary andfundamental entitlements) it should be emphasized thatthe people are not means for development alone but areits vital ends. So that, in crafting policies and social safety
nets the well-being of the entire population must comefirst before anything else.
Equality of capability and government policies
As the virus continues to rapidly spread globally,
afflicting more or less 3 million people across 210
countries and causing thousands of deaths, nations allover the world are imposing strict measures in the hopeof containing and stopping the rapid increase of COVID19 infection. While the imposition of strict social
distancing and lock down measures have been provenefficient in containing the virus in most high-income
societies, the same measure of strict social distancing
may not necessary yield similar positive result to poorer
societies. We have learned that strict social distancing
measure has been a corner stone of most rich countries’
response to COVID-19 pandemic. However, imposing thesame strict draconian measure may not necessarily fit to
the needs of poorer communities; and its unintended
and inevitable consequences may even be as equally
deadly as the virus.
A community whose state of living is utterly
dependent on informal economy, and people needs towork every day to bring food to the table, a sudden haltof economic activities and the imposition of stay at homemeasure are proven to be disastrous. “When states have
limited budgets and capacity to support their lockeddown population, lockdowns can result in widespreadstarvation and rampant disobedience and unrest (Piper,2020).” Almost immediately after the entire world
placed itself in lockdown, narratives of unrest and theclamor of unfair treatment in poorer societies havegrown each day. “In Kenya, police beat people for defying
a stay-at-home order and shot to death a 13-year-old boy
who was standing on his balcony. Human rights activistsin Nigeria say that at least 18 people have been killed by
security forces enforcing the lockdown. In India,
reported cases of deaths caused by starvation due tostrict social distancing measure surfaced in the daily
news, and the news of an impending national lockdown
sent millions of laborers fleeing for the rural areas where
they hoped they could find food during the shutdown(Piper, 2020).”In the Philippines, after the President imposed lockdown policy in the country’s capital and the entire islandof Luzon, other provinces and municipalities followed
the same protocol in the hope of containing possible
contagion of COVID-19 and flattening the curve. But,
since the implementation of strict social distancing
measure there have been litanies of unrest and struggles
on the part of the poor that surfaced on the daily news in
the country. The meandering policy of lockdown in the
country has caused the majority of the population to fear
for their well-being. Hundreds of poor Filipinos areincarcerated due to the alleged -transgressions of the
lockdown policy. Cases of excessive application of force,on the part of the law enforcers in apprehendingEubios Journal of Asian and International Bioethics 30(5) (June 2020)
violators are almost ordinary as the “stay at home”
policy continues in the country for another two weeks.
Last week (April 22,2020), a retired military man who
was suffering from a post traumatic disorder was shotdead by a police officer in a checkpoint in Quezon city forallegedly attempting to pull a gun on the cops (CNN
Philippines, 2020). Last Monday (April 28, 2020), an
ambulant fish vendor who was allegedly violating thecommunity lockdown order was mauled by barangay
officials of South Triangle in Quezon City, he sustained
several wounds and abrasion in different parts of his
body caused by the beating. These and other lockdown
incidences allow us to see the problem in theimplementation of a “one-size-fits-all-approach” indealing with the global pandemic. As many nations areencouraging the strict implementation of social
distancing in order to contain the virus, for those people
living in extreme poverty, this certainly is an additionalburden. “For the Philippines, where it was reported that
one in five people in the country live below the poverty
line, impoverished communities in the densely
populated city of Manila struggle to adhere to thepractice (Nortajuddin, 2020).” Strict draconian measuresin high income societies may have been effective inflattening the curve, for they have both: the economic
capacity to sustain the well-being of their locked-down
populations and a well-established and well-preparedhealth care system that assures the population of theirpositive health. However, in most developing countries
all the aforementioned capabilities are mostly absent, sothat any restrictive measure undertaken by thegovernment that are empty of concrete plans, as in thecase of social safety nets that will reassure theimpoverished members of their subsistence during theperiod of lockdown, will only yield catastrophic results.
Any government response measure directed towards
balancing the social and economic impact of the recent
global pandemic must intricately take into account thepositive freedom of the individual to achieve well-being
expressed in at least the freedom to live well.
Development as well-being freedom must be theultimate criterion in grafting feasible policies that may
sustain the well-being of the poor during a health crisis.
To illustrate, consider the recent policy of putting
everyone into lockdown. Although it has been proventhat in most rich countries lockdowns wielded positive
results. However, this may not necessarily be the case inmost developing countries. One cannot just turn a blindeye to the inevitable dreadful effects of lockdowns to thepoorest of the poor whose lives depend on theireveryday struggle outside begging for their everyday
subsistence. For the rich being in lockdown is a privilege,a peculiar immunity and a grace to be reunited with theirlove ones and to be safe under their often gated andwell-guarded homes in their richly elaborated
subdivisions. But for the poor living in the urban slums
and in their dilapidated shanties wherein physicaldistancing is an impossibility and whose subsistence
depends on their day to day income being landlesslaborers, such policy is experienced as a slow andagonizing chastisement that causes their everyday
anxieties. The rich and the poor being in lockdown may
have the same level of wellbeing, in terms of being underconstraint to move freely and for some maybe in terms

251

of being undernourished, as in the case when a richbeautiful lady chooses to fast during the entire
quarantine period for fear that she might gain weight in
the end. Nonetheless, there remain a vital difference
between the two; the rich with her affluence and politicalconnections can easily choose otherwise, like when acertain senator attended a birthday party despite being
under observation, while the poor, impoverished andundernourished, is forced to suffer owing to her state ofabsolute capability deficit. Sen points out that "in judging
a person's advantage (the kind of deal that he or she hasgot), the importance of well-being freedom must berecognized (Sen, 1984: 201)."
It is noteworthy to emphasize that this is not todisregard the effectivity of lockdown in flattening the
curve of the pandemic, for we have learned that it cansave lives by cutting the chain of infection within thecommunity. Rather, what is being argued here is that a“one-size-fit-all approach” in dealing with the pandemic
may have unintended consequences that arecatastrophic and deadly especially to countries that are
struggling due to systemic deprivations and absolute
poverty. Locking down an entire family, whosesubsistence greatly depends on their ordinary lives
outside looking for income and food being daily laborers,
without immediate aid and feasible social safety nets
that will guarantee their subsistence will inevitably
result to catastrophic ends.
Moreover, aside from the aforementioned problems
of individual subsistence and development during the
pandemic, problems on the well-being and protection ofhealth care professionals arise in most developing
countries arise due to their often lax and inefficient
health care system. The lack of a well-established anddeveloped health care system further complicates theconditions of most of the impoverished countries
infected with the virus. Accordingly, there has been”
approximately 423 healthcare professionals (HCP) [who]have died of COVID-19 around the world, with Italy
having the greatest number of HCP deaths, estimated ataround 106 fatalities as of April 15 (Ichimura, 2020).”
Furthermore, based on the report given by the
Department of Health last Monday (April 27, 2020), thePhilippines have recorded 1,245 cases of health care
professionals infected with the COVID-19 virus and adeath toll of 27, constituting of nurses and doctors who
succumbed to the disease (CNN Philippines, 2020). The
health department said that among the aforementioned
cases of healthcare workers infected with the virus are
464 doctors, 471 nurses, 69 nursing assistants, 41
medical technologists, 25 radiologic technologists, and10 midwives (CNN Philippines, 2020). The high incidentof COVID-19 positive among the country’s healthcare
professionals has raised concern to the World HealthOrganization, Dr. Abdi Mahamud, WHO-Western PacificRegion COVID-19 incident manager said that thealarmingly high COVID-19 cases in the country among its
health professionals may have been caused by “the lackof personal protective gears, its improper use, or theincreasing number of cases overwhelming the healthcare
system (CNN Philippines, 2020).” According to reports,
the Philippines is one of the countries in the world thathas high COVID-19 incidence and mortality rate amongits healthcare professionals. One can expect that the252

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

recorded number of COVID-19 cases in the country
among healthcare professionals are expected to rise as
the country is scrambling to reconfigure its system at thelast minute; problems of limited test kits, lack ofpersonal protective equipment and the need for proper
facilities and technologies to care for the infected, andthe subsequent rising of COVID-19 incidence will persist
until the government will take feasible alternative
response measures directed towards resolving thepressing problem.
Strengthening
thePhilippines’
institutionalframework: The country’s institutional framework fordisaster risk and management is currently being
strengthened with the creation of the new department
for disaster risk and resilience. The new department istasked to monitor the COVID-19 pandemic’s impact tothe socio-economic life of the country’s population andthe overall state of wellbeing of the country during the
global outbreak. It is directed towards securing thebalance of the economic and social objectives which are
under constant threat by the pandemic. Facing theimpacts of the global outbreak and in the hope ofboosting its resilience and capacity to recover from theonslaught of COVID-19, the Philippines applied for its
Third Risk Management Development Policy Loan of
USD 500 million and was approved by the World Bank’s
Board of Executive Directors last April 9, 2020. The
finance loan is directed towards boosting the country’s
capacity to address disaster risks, recover from naturalcalamities and support urgent needs brought about by
COV-19. The Department of Finance’s report on COVID19 socio-economic response last April 14, 2020
reiterated the government’s “Four-Pilar Socio-Economic
Strategy Against COVID-19”. The framework consistedof: 1. emergency support for vulnerable groups; 2.
marshalling resources to fight CVID-19; 3. fiscal andmonetary actions to finance emergency initiatives andkeep the economy afloat; 4. An economic recovery plan
to create jobs and sustain growth (Department of
Finance report on COVID-19 Socio-Economic Response,2020). The first pillar is directed towards supporting the
18 million low-income families and the 1.2 million
unemployed Filipinos due to the COVID-19 lockdown. It
consists of credit guarantee, loans, wage subsidy
intended to support the unemployed during the
pandemic and the social amelioration program of 5000
to 8000 per month subsidy program. The estimatedbudget for this emergency support is USD 11.5 billion.
The second pillar is aimed at providing support for thecountry’s healthcare workers, through expansion of
medical resources to fight COVID-19 and to ensure thesafety of the frontliners, it has an estimated budget of
USD 702.8 million. This includes the procurement of
medical equipment and supplies, loans for COVID-19
facilities, the procurement of 1 million pieces of PPe(personal protective equipment), PhilHealth medical
assistance and expenses of COVID-19 patients, andcompensation of private facilities used for the purpose offighting COVID-19. The third pillar is aimed at sustaining
the economic welfare of the country during the
pandemic with the estimated budget of USD 16.3 billion.
The fourth pillar is intended to sustain small businesses
during the health crisis. The government will provide

wage subsidy to some 3.4 million EQC-affected
employees of small businesses; the estimated cost of the
program for two months is from 38.1 to 51.0 billion
pesos growth (Department of Finance report on COVID19 Socio-Economic Response, 2020).
Conclusion
Although most of the countries that have been hit hardby the global outbreak, in terms of the number of casesand deaths recorded worldwide, are from high income
societies, most of the developing countries and thepoorest of poor communities remain to be the mostvulnerable casualties of the devastating anddehumanizing effects of the pandemic. COVID-19 sees
no borders, it does not choose who will be its next
victims. The rich and the poor can be infected; and while
the rich communities have the capability to deal with thedisease and to sustain the well-being of their members,poorer societies are left on their own scrambling to
defend themselves against the ravaging COVID-19
pandemic with their scares resources and deplorable
states of being. The deplorable state of existence among
the global poor, the lack of sanitation, access to cleanwater, proper nutrition, education, proper housing,efficient and affordable healthcare services, makes mostof the developing countries and the poorest of the poor
communities more susceptible to the disease. Questions
on development and well-being become significantly
relevant when confronted with the prevailing threat of
the global pandemic. Many nations across the globe havetaken decisive and diversified measures to contain thevirus in the hope of finally ending the global outbreak.
As nations differ in economic statuses, the effectivity ofthe measures they undertake in battling against the virus
likewise differs. Certainly, the rich communities are wellcapacitated to sustain the well-being of their nations andtheir members. However, this might not be the case inmost developing countries and poorer societies which
are struggling from social inequalities and injustices. Lefton their own during this difficult time, the poorest of thepoor communities will helplessly succumb to thedevastating effects of the virus. A one-size-fits-all approach may not necessarily yield the same result as tosome who successfully applied the similar approachespecially to most developing and impoverished nations.
Any government response measure intended to resolve
the pressing problem brought about by COVID-19 indeveloping countries in the south must sensitive to thedevelopment of everyone’s positive freedom expressedin the freedom to live well and to be well protected andaided during the global outbreak. Living well entails
being capacitated to project for the worthwhile life one
has reason to value.
References
Anand, S. and Sen, A. 2000. The Income Component of the
Human Development Index. Journal of Human Development,
1 (1), pp.83-106.
Athira Nortajuddin 2020. Surviving the virus lockdown. At:
https://theaseanpost.com/article/surviving-virus-lockdown
CNN Philippines 2020. COVID-19 cases among healthcare
workers now at 1,245; death toll at 27. Available in;https://www.cnnphilippines.com/news/2020/4/27/covidcases-PH-healthworkers.html.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
CNN Philippines news. Retired soldier shot dead by police atcheckpoint in Quezon City. https://www.cnnphilippines.
Department of Finance Report on COVID-19 socio-economic
response.
At:
https://www.dof.gov.ph/download/dofreport-on-covid-19-socioeconomic-responseapril-14-2020/
Des Gasper 2002. Is Sen’s Capability Approach an Adequate
Basis for Considering Human Development?, Review ofpolitical Economy, 14;4, pp. 435-461.
Dreze, Jean and A. Sen2002. India: Development andParticipation. Delhi: Oxford University press.
Ichimura, Anri 2020. COVID-19 Has Killed Over 400 Doctors
and Nurses Around the World: Approximately 423
healthcare professionals have died of COVID-19 around theworld.
Availablein;https://www.esquiremag.ph/politics/news/ph-healthcarefatalities-a00304-20200415
Robeyns, Ingrid 2000. “An Unworkable Idea or a Promising
Alternative? Sen’s Capability Approach Re-examined.”
Katholieke Universiteit Leuven 12: 1-30.
Sen, Amartya 1999. Development as freedom. Oxford: Oxford
University Press
Sen, Amartya 1984. Well-being, Agency and freedom: The
Dewey Lectures. The Journal of Philosophy, vol 84, no.4, pp.
169-221.
Sen, Amartya 1985. Standard of Living: Lecture 1 Concepts andcritiques. Cambridge: Cambridge University Press. pp. 15-51.
Sen, Amartya 1984. Well-being, Agency and freedom: The
Dewey Lectures.
The World Bank 2020. Poverty. Article online. Available at:http.www.worldbank.org.
World Vision 2020. Global Poverty and how to Help. At:
https://www.worldvision.org/sponsorship-news-stories/
global-poverty-facts-and-how-to-help

Community quarantine in the Philippines- Leandro S. Estadilla
St. Paul University Quezon City, the Philippines
Email: kurtlean@yahoo.com

Abstract
The Philippines current administration with therecommendation of the Inter-Agency Task Force on
Emerging Infectious Diseases (IATF-EID) and in
adherence with the World Health Organization Interim
Guidelines
implemented
community
quarantine
measures to combat the continuous increase in thenumber of infected cases of COVID-19 in the country.
This paper discusses the different community
quarantines being implemented on the different parts ofthe country and how these measures helped in“flattening the curve” of COVID-19 infections.
Recommendations in enhancing the fight against thevirus is presented at the end of the paper.
Introduction“The world is facing another battle. A war where theenemy is not seen nor heard, a war where health care
professionals and not soldiers are in the forefront, andcooperation of everyone is needed.” – Rodrigo Duterte,
President of the Philippines.
The year 2020 has been very dramatic, an Australian
wildfire had been felt, burning down thousands ofhouses and disrupting the ecosystem in that part of theworld. There is also a spark of conflict between Iran andthe United States of America and a recent exchange of253

gun shots between the South and North Korea at theirborder. In the Philippines, phreatic eruption of the Taal
Volcano is experienced, displacing more than 25,000
people from their home (CNN, 2020) and triggering the
local government to declare state of calamity in the area.
But of all these, the pandemic Novel Coronavirus,
commonly called as COVID-19 is the worst and put every
important aspect of life in a halt.
The virus, according to some experts first discoveredin Wuhan, China started to spread in almost all countries
in the world, infecting individuals in an enormous
progression. Currently, COVID-19 affected more than
three million people in the whole world (3,584,118)
resulting to almost two hundred and thirty thousand
deaths (251,562) as of May 5,1:00 PM PhST
(https://coronavirus.jhu.edu/map.html).
When World Health Organization (WHO) firstannounced an outbreak of the coronavirus on January
30, thru Public Health Emergency of International
Concern, they also provided measures that every country
should follow to prevent a human-to-humantransmission of the virus (WHO, 2020). On their Interim
Guidance in March, 2020, they mentioned that “toachieve these goals (prevention of transmission),countries may include quarantine, which involves the
restriction of movement, or separation from the rest of the
population, of healthy persons who may have been
exposed to the virus, with the objective of monitoring their
symptoms and ensuring early detection of cases”. These
measures will help the member nation to lessen theeffect of infections among the population. They cited aswell that a person who have had an exposure with aninfected individual must do a quarantine for at least 14days (WHO, 2020). The separation of a carrier of thevirus for two (2) weeks from other people will safeguardthat other people will not get infected.
Social Science in Humanitarian Action (2020)
provided three (3) measures on how to restrict the
movements of the populace at this time of COVID-19
pandemic. These measures are quarantine, isolation, andsocial distancing that can be implemented mandatory or
voluntary in nature. Quarantine is defined as when:“individuals who have been exposed to a communicabledisease are separated from others for the duration of thedisease’s incubation period; isolation is when individuals
with a communicable disease are separated from others
for as long as they are infectious; and social distancing, inwhich individuals or large groups of people are
restricted from gathering”.
Enhanced community quarantine (ECQ)On March 15, President Rodrigo Duterte (PRRD) places
Metro Manila, the capital of the Philippines in an
Enhanced Community Quarantine (ECQ) and two days
after, to the entire Luzon island, this measure is
supposed to last until April 13. The decision in
implementing the policy is recommended by thecommittee that the president himself created -- theInter-Agency Task Force on Emerging Infectious
Diseases (IATF-EID). The IATF-EID is composed ofexperts in different fields like health, public safety, policy
makers, economists, among others. They are expected toresolve the issue that the country is facing in relation of
the pandemic.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

The recommendation of the IATF-EID is aligned withthe objective of stopping the wide spread of the virus in
the metropolis, and its neighboring provinces and toother parts of the country. However, on April 7, thespokesperson of IATF-EID confirmed that PRRD
approved another recommendation of extending the
lockdown until April 30.This extension is based on thefollowing: cases of infections will rise when the
lockdown is lifted, the Department of Health (DOH) of
the country needs more time to ramp up its testing
capabilities and test results turn around, and thegovernment is targeting that once results were given,
infected individuals will be immediately isolated fromthe public. These are to be done to prolong or “flatten the
curve” of infections in the country while waiting forscientists to discover a vaccine to fight the virus.
As of May 4, 3:20 PM PhST, Philippines is third among
ASEAN in terms of cases of infections of COVID-19,
posting a total number of 9,485 cases while Singapore ison top with 18,778 cases and Indonesia ranks at second
with 11,587 cases. However, in terms of deaths,
Philippines is ranked second behind Indonesia with 623
and 864 deaths, respectively. Moreover, recoveries ofpatients in the Philippines cuts through half of ASEAN
countries with a total recovery of 1,315 while the top
two countries with most recoveries are Malaysia with
4,484 and Thailand with 2,740 patient recoveries.
Negative effects of ECQ
Though the lock down would help the country “flatten
the curve”, many Filipinos expresses their negative
sentiments. In the study of Pastor (2020), the foodsupply and support of the government is a problem
experienced by many people in Luzon who expresses
their opinions thru Twitter. He further claims thatthough some tweets show positive effects, “it was
miscredited to the coronavirus instead of crediting to thedecision such as community quarantine, lockdown andsocial distancing.” The negative sentiments emanatedfrom the inabilities of the government, local and national
to implement an efficient manner of policies in allowing
the food transport from one place to another, issuing
different statements from different checkpoints
established in the capital. Another issue mentioned is the
distribution of food packs that would have been a big
help and support for people on their day-to-day living
since they are no longer allowed to work not unless they
are members of the health sector or necessity producing
businesses.
Moreover, the lockdown policy would also have a
psychological effect to the people. Quarantine according
to Rubin and Wesseley (2020), would cause panic andanxiety in the community. They enumerated reasons on
this “Firstly, the measure shows that authorities believe
the situation to be severe and liable to worsen. Secondly,
the imposition of the measure primarily for the benefit ofthose outside the affected cities reduces trust—the belief
that authorities are acting in my best interests—for thosewithin. Thirdly, quarantine means a loss of control and asense of being trapped, which will be heightened if families
have become separated. Fourthly, the impact of the rumor
mill must not be underestimated. The desire for facts will
escalate and an absence of clear messages will increase
fear and push people to seek information from less reliable

sources.” These are manifested in the case of thePhilippines during the early implementation of the
lockdown. At the time of the announcement of ECQ,
people were frightened on how serious and deadly thevirus will be and almost everyone expresses their fear on
their different social platforms. Many Filipinos, weretrapped and caught off guard on the implementation of
lockdown, several people were not able to return to theirhometown (those who are working in the capital but
originally living in neighboring provinces around Metro
Manila) and forced to stay and find shelter in the city.
Lastly, since there are quite a number of rumors
emerging from the situation, people look for non-official
source of information without verifying the truthfulnessof the material, thus, “fake news” spread like fire andhave been a big problem of the government as well.
These triggers specialists to create an information drive
to correct misinformation circulating in the country andsome physicians even establishes online consultations
for COVID-19 and mental health concerns, foreseeing theeffect of ECQ to Filipinos.
Likewise, socio-economic aspect of the country is not
safe from the effects of ECQ. National Economic
Development Authority (NEDA) of the country expected
an economic recession this year, with expected negative
growth rate in the remainder of the year. Monetary
speaking, the country is expecting to lose PHP298 billion
to PHP1.1 trillion, equivalent to 1.5 to 5.3 percent of thecountry’s GDP and an unemployment of 61,000 to 1
million persons this year (NEDA, 2020). These
contraction in the economy is primarily caused by the
sharp decline in the tourism industry of the country
since a big chunk of the economy depends greatly on the
spending of foreign and local tourists. Manufacturing is
also taking the blows of ECQ, many companies, especiallysmall and medium enterprises (SME’s) can no longer
operate since their workers are forbidden to transport
from their homes to the companies and are expectingthat no people are discouraged to spending their money
on non-essential products. But the most compellingconsequence is on the consumption of every households,
many people are no longer receiving regular income andare forced to rely on the government’s amelioration.
Each affected household, those poorest of the poor, isgiven an amelioration fund amounting to Php 5,000 toPhp 8,000 to augment the lost income due to ECQ.
Unfortunately, this amount is not enough for a family tosustain their day-to-day lives resulting to a weak
consumption and spending in the economy.
ECQ in numbers
Although the effect of the quarantine and lockdown isimminent, this would have been worst if the IATF-EID
did not implement such measure.
On her press briefing on March 18, DOH
Undersecretary estimated that in two (2) to three (3)months, the number of infected cases will be around75,000 and this will only be lessened if appropriate
interventions and strict social distancing will be
implemented by the government. This announcement is
a way of assuring the public that the situation we are in
is serious and the measure implemented by the IATF-EID
is rightful and needed to combat the epidemic. This isEubios Journal of Asian and International Bioethics 30(5) (June 2020)
also supported by the different studies made by thedifferent agencies and universities in the country.
In the study made by FASSSTER of Ateneo de Manila
University in partnership with the Department of
Science and Technology (DOST), using their modelling
techniques in forecasting the number of infected
persons, if no quarantine policy had been implemented
on March, the country would have more or less two (2)million confirmed cases by today (using an assumptionthat an infected person can infect another person inanother place in Metro Manila and people in NCR will goin and out the metro). They also claimed that number of
infected persons will decline as strict and longer
implementation of a lockdown and quarantine is put inplace. In addition, if the Luzon lockdown will be lifted at
the end of April, they computed that confirmed case of
6,800 persons by May 21 will be realized(https://pchrd.dost.gov.ph).
Another prominent university in the country, theUniversity of the Philippines (UP), forecasted that at theend of April, as the country adopted the extension of
ECQ, the infected cases will be estimated between 9,000
to 44,000 persons (https://www.up.edu.ph/modifiedcommunity-quarantine-beyond-april-30-analysis-andrecommendations/) explaining further that instead of
the cases doubling in three (3) days, the progression is
now happening in every six (6) days. Thus, signifyingthat the extension of ECQ is helping flatten the curve.
These studies among others, helped the DOH toestimates the possible peak as well as the number of
infections in the country in relation to the proposed ECQof the IATF-EID. These figures also helped them create
strategies that would mitigate the infections caused by
COVID-19 among Filipinos.
General Community Quarantine (GCQ)
Due to the continuous increase in the number of cases ofinfections, the government extended the ECQ until May
15 in Metro Manila and introduced another quarantine
measure to other parts of the country, named, General
Community Quarantine or GCQ. The new measure is
implemented to at least prevent the continuous decline
in the economic situation of the country. Under GCQ, a
new set of guidelines is to be followed, less strict thanthe ECQ.
On April 28, palace spokesman announces that “theGCQ will take effect May 1 to 15 and will be removed
thereafter for “low-risk” areas and may be extended for“moderate-risk” areas.” (https://pressone.ph/ecq-vsgcq-palace-releases-new-guidelines/). In this newmeasure, the following manufacturing sectors likebeverages (alcoholic and non-alcoholic), steel, tobacco,and textiles industries to name a few are now allowed to
do business. Further, malls catering to the personal andnecessity goods together with establishments under
personal care industries will be operating but in a strict
health standard, social distancing and limited number ofcustomers will only be accommodated. Other industries
like real estate and other selected business activities
offering services to people are also allowed. This new
development in the new quarantine is hoped to help the
economy rebound at least few percentage points for the
rest of the year, aside from the fact that people are

255

longing for these products after depriving for almost one
and a half month now.
Moreover, the palace announces that if the number of
infected cases in the capital continue to decline, thoseunder ECQ will be converted into GCQ on May 15, thus,
encouraging everyone to observe how the new measure
works in other places that already under GCQ.
Extreme Enhanced Community Quarantine (EECQ)
Though there are provinces in the country who
experiences decline on the number of infected cases,
there are also municipalities in the capital thatexperiences the worst. A spike on the number of cases incertain places is felt and led to the creation of theExtreme Enhanced Community Quarantine (EECQ), as
some called it “hard lockdown”.
Under this measure, only residents who were issued
a quarantine pass from the barangay or municipality canleave their homes to buy essential goods and in doing so,
are always expected to wear masks. Further, businesses
under EECQ is limited to selling only necessity goods at alimited time of operation. But there are also some local
government units (LGU’s) who implement a stricter
EECQ measure. They are no longer allowing people to go
outside their homes not unless in emergency cases,
commerce is closed, and soldiers and policemen aretasked to monitor and implement more stringent
sanctions to violators, paying heftier fee or placing
violators behind bars. Food and other essential goods
are provided by the LGU who makes use of the situation
to further their mass testing for COVID-19 infections.
Conclusion
The implementation of Community Quarantine (CQ)
greatly helps the country to at least slows down theeffect of a widespread infection of the virus not only inthe capital but also in neighboring provinces. Thoughsome negative consequences are experienced, these are
only small amounts of sacrifices the country and its
people must do in order to lessen the further damage of
COVID-19 in the future.
Many Filipinos are agreeable with the quarantine
measures implemented by the authorities. People
believe that these limits the transmission of the virus
from one person to another and helps the government
identify who among are infected and who are not. One
way or another many are following the measures
especially in the urban areas, maybe because they are
the members of the population who have enough spacesin their homes to accommodate social distancing.
Unfortunately, this measure is not applicable to those
who do not have enough place in their homes and haveinsufficient funds to support their daily needs, these are
citizens living in the slum areas. These people are madeto choose between violating the guidelines set by theadministration to finding extra income and disobeying
the guidelines of the CQ.
In administering quarantine measures, effectivity will
be realized if the citizenry is provided their needs tosurvive all throughout the lockdown, essential products
for survival and health support. If the government fails
to do its job, people will be forced to go out their homes,
into the streets and look for ways to earn money tosupport their families.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

Moreover, quarantine is only one of the steps to beundertaken by the government to combat the deadly
virus. Mass testing of those suspected and are exposed to
the virus must be implemented, and in a most efficient
way possible. There had been news that only those who
are well-off are privileged to be tested and this does not
sit well with many people. Knowing who among the
population are infected should be treated and provided
with care in order to lessen the spread of the virus toothers, especially the vulnerable members of the society.
The virus is causing lots of deaths of people who are 60
years old and above and those people who havecomorbid cases. Lastly, availability of hospitals forpatients’ care must be provided to the infected andshould be treated with utmost care. Though resources of
the government are scarce, an efficient manner of
allocating and using the budget for the pandemics willcertainly go a long way and save many lives.

The attainment of such stage is based on hope of thepatient to receive mercy and forgiveness of God. And theway of attainment of hope is possible by doing therepentance, praying, and patience. In combating the pain
and suffering, the patient is supposed to understand thatthe life in its reality is a test and facing such a test is
possible by two ways, one is patient centric by building
patience within to endure the suffering and second isseeking help from God by praying. For the spiritual wellbeing, the patient should understand that his suffering isin fact expiation for his sins. On the other hand, thevisitors and caregivers of patients have certain
responsibilities that contribute to enhancing of thespiritual well-being of the patient, including comfortingthem by giving hope to the patients and at the same timepraying for their recovery. These all elements enhance
the spiritual well-being of patients and help inprevention of suffering by spiritual means.

References

Introduction
World Health Organization (WHO) defines palliative careas “an approach that improves the quality of life ofpatients and their families facing the problem associatedwith life-threatening illness, through the prevention andrelief of suffering by means of early identification and
impeccable assessment and treatment of pain and otherproblems, physical, psychosocial and spiritual” (World
Health Organization, 2012). Furthermore, it says thatpalliative care beside other elements “integrates thepsychological and spiritual aspects of patient care”(World Health Organization, 2012). This article is about
spiritual care of such Muslim patients who are terminally
ill or face life-threatening illness. The spiritual well-beingof the patients has two-fold benefits and aspects: the firstone is providing a spiritual relief to patients to cope with
the illness and its associated problems such as anxiety,discomfort, and despair, and the second one is helping
patients to be spiritually at peace in case there is highcertainty that their illness is life-threatening or they are
terminally ill.
An Islamic approach from its theological sources toaddress the spiritual issues concerning the palliative
care of the patients with life-threatening illness could beestablished on a spiritual construct that is attaining a
stage of self or soul (nafas) called as reassured soul(nafs-e-mutmainna). The initial state of self (nafas)
should be between the fear (khawf) of God and hope(rajja) from God. And to overcome and minimize theelement of fear (khawf), the patient should perform
repentance (tawbah). On the other hand, the patient
while coping with sickness should realize that the realityof life is a test (ibtillah) from God, and facing such test is
possible by two ways. The first is the patient centric bybuilding patience (sabar) within to face the sickness andthe second is seeking help from God by praying (salat) tohim. The test leads to the concept of expiation (kafarah)of the sins and misdeeds. In other words, suffering has apositive meaning in Islam as expiation of sins. On theother hand, there are certain spiritually meaningful
responsibilities of caregivers and visitors of patientssuch as to pray for their healing and giving them hope bysaying positive and optimistic words.

COVID-19 Dashboard by the Center of for Systems andEngineering (CSSE) at Johns Hopkins University; 2020
https://coronavirus.jhu.edu/map.html (accessed 5 May
2020)
FASSSTER than COVID-19: The science used to forecast COVID19 in PH. (2020 April 8). Retrieved from accessed 18, April
2020.
Key considerations: quarantine in the context of COVID-19. In:
Social Science in Humanitarian Action: A Communication
for Development Platform [website]. New York: UNICEF,
InstituteofDevelopment
Studies;
2020
https://www.socialscienceinaction.org/resources/february2020-social-science-humanitarian-action-platform/(accessed 29 February 2020)
National Economic Development Authority (NEDA) Report.
(2020,March).
Retrievedfrom
http://www.neda.gov.ph/wpcontent/uploads/2020/03/NEDA_Addressing-the-Socialand-Economic-Impact-of-the-COVID-19-Pandemic.pdf
Pressone.ph. (2020, Apr. 28). ECQ vs. GCQ: Palace releases new
guidelines. Retrieved from https://pressone.ph/ecq-vsgcq-palace-releases-new-guidelines/, accessed May 1,
2020.
Rubin, J. and Wesseley S. (2020). “The psychological effects ofquarantining a city”. The BMJ UK. BMJ 2020;368:m313
UP Covid-19 Pandemic Response Team. (2020, April 13).
Modified Community Quarantine beyond April 30: Analysis
and Recommendations. At: https://www.up.edu.ph/modified-community-quarantine-beyond-april-30-analysisand-recommendations/, accessed 18 April 2020.

Enhancing spiritual palliative care ofMuslim patients: a perspective from Islamic
theology-Mohammad Manzoor Malik
Lecturer, Department of Philosophy and Religion, Graduate
School of Human Sciences, Assumption University of Thailand
E-mail: philomalik@gmail.com; mmalik@au.edu

Abstract
An Islamic approach from its theological sources toaddress the spiritual pain related to palliative care ofterminally ill patients can be established on attaining a
spiritual stage of soul or spirit termed as reassured soul.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
In the subsequent parts of this paper, the above
arrangement and scheme of the concepts are followed
accordingly.
Reassured Soul (nafs-e-mutmainna)
Attaining reassured soul, the secure self, or the soul atpeace (nafs-e-mutmainna) by the end of life is a goal andwish of every Muslim. It is a state of attaining peace withand pleasure (rida) of God. The purity of soul andperfection is desired because Muslims believe that theycome from God and to him they will return, as The Quranstates “Indeed we belong to Allah, and indeed to Him we
will return” (The Quran, 2: 156). Furthermore, the life
according to the Quran is impermanent therefore aperson should be prepare for the hereafter and the “…
hereafter is better …” (The Quran, 87: 16-17) for the
believer.
According to The Quran it is the purification of soulthat leads to success and it is its corruption that leads tofailure as it states “…Truly he succeeds that purifies it(self or soul), and he fails that corrupts it!” (The Quran,
91: 7-10).The Quran describes three stages or types ofself (nafas): the soul which commands and encourages
doing sin, (nafs-e-ammara), as it is stated in the Quranthat this soul “… overwhelmingly commands a person to
do sin.” (The Quran, 12:53). The second type of soul isblaming, or regretting (nafs-e-lawwama). The Quranstates that “And I (God) swear by the reproaching soul.”(The Quran, 75:2). It is a guilty soul that eventually leads
to shunning the sinful life .The third is reassured soul(nafs-e-mutmainna).
The reassured soul or self (nafs-e-mutmainna) iswhat a Muslim wishes to attain before death. Regarding
this soul, the Quran states that to the righteous it will besaid at the time of death, “Oh reassured soul, return toyour Lord well pleased, and pleasing to Him.” (The
Quran, 89:27-28). Al-Tabari explains nafs-e-mutmainna
as reassuring, as it is reassured of the promise of God,
which he promised the people of faith with of dignity inthis world and in the afterlife, and thus the soul ratified
it. Ibn Abaas says reassured soul means ratifying self,
Qatadah says reassured soul means the believer who
reassured himself of the promise of God. (Al-Tabari, v.
24, P. 393). This soul is peaceful. At the time of death theangle of death sitting by the side of dying person
addresses him by saying, “O pure soul, come out to theforgiveness and pleasure of Allah’. Then his soul comesflowing out like a drop of water flowing from a cup…”(Musnad Ahmad ibn Hanbal , h. 17803).
Therefore, it is the perfection of soul or in otherwords attaining reassured soul that concerns a Muslim
patient. And attaining such stage of soul is what mattersmost in fulfilling spiritual need of a patient in providing
relief as the crucial element of the palliative care of aMuslim patient. Muslims believe that after death the
body decays but the soul remains and the soul either
receives the pleasure and tidings of God or it receives
torment and displeasure of God. A righteous soulreceives the glad tidings of mercy then it is taken up to
heaven and it is said to him “welcome to the good soulthat was in a good body. Enter praiseworthy and receive
the glad tidings of mercy and fragrance …” (Ibn Maajah,
v. 5, h. 4262). The state of reassured soul or self (nafas)

257

should be in between the fear (khawf) of God and hope(rajja) from God.
Hope (rajja) and Fear (khawf)
The best condition and a state of life of a believer inIslam is that he should be living between the fear
(khawf) and hope (rajja). He should have fear of God andat the same time he should not be hopeless of his mercy
even if one is convinced that he /she has attained thestate of reassured soul (nafs-e-mutmainna). There should
be balance between fear and hope and this balance keeps
a person mindful of his duties and striving for thepleasure of God. The Quran states that “…they call on
their Lord, in Fear and Hope… (The Quran, 32:16).
Therefore, for the reassured soul with which God is
pleased is the one that is fearful of God as the Quranstates, “… Allah is well pleased with them and they are
well pleased with Him; that is for him who fears his
Lord”. (The Quran, 98:8).
Though a believer is supposed to be between fear andhope, yet the teachings from the theological sources givehigher importance for being hopeful of God’s mercy.
There is a message of hope in the Quran, not to be
despairing as The Quran states that “O my Servants who
have transgressed against their souls! Do not despair ofthe Mercy of Allah … (The Quran, 39:53). Furthermore,
God is with you and will never deprive you of your (good)deeds. (The Quran, 47:35). The Messenger of Allah said,“Allah the Exalted says: 'I am as my slave expects me tobe…”. (Sahih al-Bukhari, v.9, h. 502). Therefore, a patient
should expect the mercy and forgiveness of God.
To minimize the element of fear and maximize theelement of hope, there are certain acts a patient canfollow. Among those acts is repentance (taubah) andasking forgiveness (maaf) from people who the patient
may have wronged in the past.
Repentance (taubah) and Forgiveness (maaf)
There is an essential aspect of human beings and that ishuman imperfection. Just like ordinary human beings, apatient under the palliative care is assumed to have lived
with human experience that is imperfect in the sensethat such experience may have been comprised of
mistakes and sometimes of misdeeds. To gain thespiritual strength, it becomes necessary that such apatient should cleanse himself and feel a spiritual stateof purity. Among those acts that can help the patient tocleanse himself is repentance (taubah) and asking
forgiveness (maaf) from people who the patient may
have wronged in his past.
Repentance (taubah) means that one feels regret for
his or her sins and turns to God without any intercession
with the intention to obey him.And it is only God who
can forgive, The Quran states “Will they not, then, turntowards God in repentance, and ask His forgiveness? For
God is much-forgiving, a dispenser of grace” (The Quran,5:74) and “Hence, ask your Sustainer to forgive you yoursins, and then turn towards Him in repentance …" (The
Quran, 11:9). Sheikh Saleh Al - Karbasi explains
repentance as the return to the path of God after
deviating from it.And repentance can only be achievedby regretting the acts of evil, and by the determination toleave sins and not to return to them, with theseriousness in restoring the rift in the life of human258

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

moral because of those sins and by amending the lost
rights of people and the rights of God.After all this, if aperson sincerely asks forgiveness, God will accept his
repentance (https://www.islam4u.com). The Quranstates, “But as for those who do bad deeds andafterwards repent and [truly] believe-verily, after suchrepentance thy Sustainer is indeed much forgiving, adispenser of grace!” (The Quran, 7:153).
Therefore, a patient should perform repentance andseek God’s forgiveness without any delay before the timeof death or while facing a serious illness. Because,“whereas repentance shall not be accepted from those
who do evil deeds until their dying hour …” (The Quran,4:18). “But as for him who repents after having thus
done wrong, and makes amends, behold, God will accept
his repentance: …” (The Quran, 5:39) “…Verily, God loves
those who turn unto Him in repentance and He loves
those who keep themselves pure” (The Quran, 2:222).
The above mentioned concept of repentance iscomprehensive of repenting the misdeeds a person may
have committed by violating the commandments of God
and other beings.
However, if a patient has wronged any fellow humanbeing such a patient should ask the person to forgive
him. This concept could be called as forgiveness (maaf).
The Prophet Mohammad says, “The poor of my Ummah
would be he who would come on the Day of Resurrection
with prayers and fasts and Zakah but (he would findhimself bankrupt on that day as he would haveexhausted his funds of virtues) since he hurled abuses
upon others, brought calumny against others andunlawfully consumed the wealth of others and shed theblood of others and beat others, and his virtues would be
credited to the account of one (who suffered at his hand).
..”( Sahih Muslim , b. 32, h. 6251). By performing
repentance (taubah) and seeking forgiveness of persons
a patient may have wronged in some way, the patient
will gain a spiritual peace. Being at peace with God andfellow human beings.
Test (Ibtilah)
The concept of test (ibtillah) is connected with worldly
life. In Islam, there are tests and trials that a person may
face in living his life. Prophet Muhammad said, “If God
wants to do good to somebody, He afflicts him withtrials.” (Saheeh Al-Bukhari, v. 7, h. 548) These tests canbe in the form of disease, loss of property, danger,
hunger etc. In face of these tests, a Muslim whether sickor healthy is supposed to be the best in his conduct andshow patience. The Quran states, “And most certainly
shall We try you by means of danger, and hunger, andloss of worldly goods, of lives and of [labour's] fruits. But
give glad tidings unto those who are patient in adversity”(The Quran, 2:155). "Every soul shall have a taste ofdeath: and We test you by evil and by good, by way oftrial. To Us must you return." (The Quran, 21:35).
The concept of ibtilah (test) shows that a Muslim patientin face of losses, diseases, should have will to live inpatience. Thinking that by the best conduct in his
adversities he will get reward from God. The Prophet
says, “Strange are the ways of a believer for there is goodin every affair of his and this is not the case with anyone
else except in the case of a believer for if he has anoccasion to feel delight, he thanks (God), thus there is agood for him in it, and if he gets into trouble and shows
resignation (and endures it patiently), there is a good for
him in it.”(Muslim, b.42, h. 7138).
Patience (sabar) and Prayer (salat)
In facing adversities, A Muslim patient is supposed to bepatient and at the same time, the patient should seek
help from God by praying to him. Being patient and at
the same time praying enhances the spirituality of thepatient and gives him will to live peacefully.
In face of the adversities, a Muslim is supposed toadhere to patience (sabar) and seek help by praying(salat). The Quran states “And seek aid in steadfast
patience and prayer: and this, indeed, is a hard thing for
all but the humble in spirit” (The Quran, 2:45). In otherplace God repeats, “O you who have attained to faith!
Seek aid in steadfast patience and prayer: for, behold,
God is with those who are patient in adversity” (The
Quran, 2:153) “…and bear in patience whatever [ill] may
befall thee…” (The Quran, 31:17). This patience is going
to be fruitful in the hereafter as the Quran states “…
reward them for all their patience in adversity” (The
Quran, 76:12). Muslims are supposed to advise eachother abiding to patience and mostly when any adversity
befalls them and the Quran states “and being, withal, of
those who have attained to faith, and who enjoin upon
one another patience in adversity, and enjoin upon one
another compassion” (The Quran, 90:17). Besides
praying, a Muslim patient should keep repeating thebeautiful names of God (zikrullah) “And (all) the Most
Beautiful Names belong to God so call on Him by them.”(The Quran, 7:80) because such remembrance of God
leads to the peace of heart as the Quran states, “…Verilyin the remembrance of Allah do hearts find rest!”(TheQuran, 13:28).
Expiation (Kafarah)
Kafarah means expiation of sins. According to Islam
people will receive reward or punishment according totheir deeds either in this world or in hereafter. The
punishment is not mechanical that it will necessarily
follow by committing a misdeed because God is merciful(Raheem) so he can forgive and his forgiveness cane besought by seeking and asking is forgiveness (istigfar) by
supplications (dua). Furthermore, any harm or sickness
that may befall a Muslim is expiation for his sins. And
this concept is called as Kafarah. It is reported in theProphetic traditions that whenever the Prophet went toa patient, he used to say to him, “Don't worry, if Allah
will, it will be expiation (for your sins….” (Sahih alBukhari, v. 7, h. 560). Furthermore, the Prophet said:“No calamity befalls a Muslim but that Allah expiates
some of his sins because of it, even though it were theprick he receives from a thorn." (Sahih al-Bukhari, v. 7,
h.544). Similarly, “No fatigue, nor disease, nor sorrow,nor sadness, nor hurt, nor distress befalls a Muslim, even
if it were the prick he receives from a thorn, but that
Allah expiates some of his sins for that." (Sahih alBukhari, v. 7, h. 545).
Therefore, the above concept of kafrarah is also
important to remind a patient that his illness and pain is
in fact a spiritual growth for himself so it can make thepatient feel better spiritually.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
On the other hand, there are certain spiritually
meaningful responsibilities of caregivers and visitors ofpatients such as to pray for their healing and giving themhope by saying positive and optimistic words.
Visiting Sick Person (iyadah al-marid)
Some of the scholars are of the view that it is an
obligatory duty (Sunnah muakkadah) of every person tovisit a sick person. However, IbnTaymiyah favored theview that it is a communal obligation (fard kifaayah). Not
everybody, but at least some should visit the patient.
IbnTaymiya in al-Ikhtiyaaraat holds that it is the correct
view (https://islamqa.info/en/answers/71968/visitingthe-sick-some-etiquettes). The Prophet said: “Free thecaptives, feed the hungry and pay a visit to the sick.”(Sahih al-Bukhari, v. 4, h. 282). There are many
Prophetic traditions or narrations (ahaadeeth) which
speak of its virtue, such as the words of the Prophet(peace and blessings of Allaah be upon him): “When the
Muslim visits his (sick) Muslim brother, he is harvesting
the fruits of Paradise until he returns.” (Riyad as-Salihin,b. 7, h. 898). The visitors of the patients are supposed topray (Duaa) for the sick in the manner as narrated
regarding the practice of the Prophet by saying “Don't
worry, if Allah will, it will be expiation (for your sins)”(Sahih al-Bukhari, v. 7, h. 560). It is also narrated thatwhenever Allah's Messenger paid a visit to a patient, or apatient was brought to him, he used to invoke Allah,saying, “Take away the disease, O the Lord of the people!
Cure him as You are the One Who cures. There is no curebut Yours, a cure that leaves no disease” (Sahih alBukhari, v. 7, h. 579). So the visitors of sick persons aresupposed to cheer them up and give them glad tidings ofhealing, for that will comfort the sick person spiritually.
The Prophet is reported to have said “When you enter
upon one who is sick, cheer him up and give him hope ofa long life, for that does not change anything (of theDivine Decree), but it will cheer the heart of the one who
is sick.” (Sunan Ibn Majah, v. 1, h. 1438).
Conclusion
Handling spiritual pain of Muslim patients in palliative
care has necessarily roots in religion. And these roots
can be explored only by right understanding of therelevant subject matter from the theological sources. The
theological sources lead to a spiritual construct and thatis attaining a stage of soul called as reassured soul. The
reassured soul as a spiritual construct as explained in theabovementioned discourse consisting of many elements.
It includes the concept of hope, repentance, test,
expiation of the sins, patience, and prayer. These all
aspects of the construct are patient centered. On theother hand, there are responsibilities of care givers andvisitors to pray and encourage a patient. The
practitioners such as doctors and nurses can and shouldbe part of such spiritual care. They could do so by
reminding the patient time to time about how they canbe spiritually peaceful. They can enlighten the patientwith the wisdom either by themselves or by inviting any
Muslim religious person to advise the patient. On theother hand the staff can also advise the visitors before
they meet the patient to take the spiritual needs of thepatient in consideration.

259

References

Al-Bukhari, M. ibn I. al-J. Sahih al-Bukhari. Retrieved fromhttps://quranx.com/hadith/Bukhari/USC-MSA
Al-tabri, M. bin Jarir. (na). Jamie Albayan ean Tawil ay al QuranTfasir Altiburi). Dar Hijar lil tibaeat wal nashr.
Al-Hajjaj ibn Muslim, A. A.-H. M. ibn A.-H. ibn M. ibn W. ibn K.
A.-Q. A.-Naysabur. (na). Sahih Muslim. Retrieved fromhttps://quranx.com/Hadith/Muslim/USC-MSA/
https://www.islam4u.com
Imam An-Nawawi., I. Y. ibn S. an-Nawawi. (2020). Riyad asSalihin. Retrieved from https://quranx.com/Hadith/ Riyad
as-Salihin /USC-MSA/
Ibn Majah, Imam Muhammad Bib Yazeed Al-Qazwini.
(2007). Sunan Ibn Majah. Houston, Texas: Dar-us-Salam.
Musnad Ahmad ibn Hanbal, h. 17803 in Q&A, I. (na). Where is
the soul, and What happens to it, after a Person has diedand before he is buried? Retrieved January 31, 2020, fromhttps://islamqa.info/en/answers/200530/where-is-thesoul-and-what-happens-to-it-after-a-person-has-died-andbefore-he-is-buried
Q&A, I. (na). Visiting the Sick – Some Etiquettes. Retrieved
January 31, 2020, at: https://islamqa.info/en/answers/
71968/visiting-the-sick-some-etiquettes
World Health Organization. (2012, January 28). WHO | WHO
Definition of Palliative Care. Retrieved January 31, 2020,
fromhttps://www.who.int/cancer/palliative/definition/en/

The ethical dilemma among healthcare
professionals in the midst of COVID-19
pandemic-Randy A. Tudy

Cor Jesu College, Philippines
randytudy@cjc.edu.phAbstract
The COVID-19 pandemic has stretched the limits ofhuman safety wherein individuals are not sure if they
have already contracted the virus making them always
fearful and anxious. Frontliners, like the health care
professionals (HCPs), are most vulnerable since they arehandling patients who could possibly contaminate them.
Many are terrified and are put in a difficult situation,
especially when reports are coming out as regards thealarming number of HCPs who became COVID-19
positive. These HCPs are facing an ethical dilemma.
Should they continue to work or not? Some of them left
their jobs for fear of their safety and the safety of theirfamilies. In this paper, I will argue from the lens ofrational egoism and Christian Ethics the ethical dilemma
the HCPs are facing during this recent pandemic. On the
one hand, those who are on the verge of surrenderingand those who resigned consider their self-interest
above others’. On the other hand, not continuing theirjob is compromising the principle of the common good.
The decision of HCPs in this time of crisis depends ontheir philosophical stance and/or their religious faith.
However, I further argue that the real equalizer is theassurance of their safety brought about by the provisionof personal protective equipment and other supporting
mechanisms.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

Introduction
The COVID-19 pandemic traumatized the people aroundworld. The health sector is trying to cope with thegrowing demands of responding to the containment of
the virus. According to the World Health Organization(WHO), as of April 8, 2020, there were 22,073 HCPs who
got infected with the virus across 52 countries (BusinessStandard, 2020).
Unfortunately, the number ofcasualties continues and all the more worrisome. Basedon the updated list of Medscape, 578 HCPS died aroundthe world with US, Italy, and Iran topping the list, as ofApril 22, 2020 (See Table 1). In Southeast Asia, thePhilippines has the highest number of casualties,
followed by Indonesia. Aside from these data, Filipinos
were shocked to learn about a large number of doctors,
and other health workers tested positive of COVID-19 in
the country. At the end of April 2020 based on the
update from the Department of Health (DOH), a total of
1,619 Filipino health workers were infected (See Table2). There was also a report about 20 Filipino healthcare
workers who died in the United Kingdom (Ramos, 2020).
The World Health Organization noticed this disturbing
data. WHO-Western Pacific Region COVID-19 manager
Dr. Abdi Mahamud sounded the alarm as the Philippines
recorded 13% of the positive COVID-19 cases came fromthe health workers, as compared to 2-3% among theregion’s 37 member states (CNN Philippines, 2020a). Heeven called this percentage as an outlier due to its
significant difference, although it is one percent lower ascompared to 14% in Spain recorded in the month ofMarch (Minder & Peltier, 2020). The statistics painted a
picture of the severity of the problem in the Philippines
and throughout the world.
If the number of positive cases increases day by day,people will become terrified. How much more for thefrontliners like doctors, nurses, and other healthprofessionals? In my previous article, I argued that the
motivation of the HCPs is driven not just by theirprofessional oath, but more on their contribution to thecommon good (Tudy, 2020). In this paper, I will shedlight on the ethical dilemma among HCPs from the lensof rational egoism and Christian ethics. This paper
contributes to the debate on whether it is ethical or notfor HCPs to refuse going to work during a pandemic.
The dilemma among healthcare professionals
A pandemic causes a lot of pressure not only to thegeneral public but all the more to the frontliners, theHCPs. It is not surprising why many of them are hesitant
to report to work for fear of acquiring the virus. In two
surveys conducted, only around 50% of the respondent
HCPs said they would report to work in the event of apandemic (Gershon, et al., 2010; Irvin, Cindrich,
Patterson, & Southall, 2008). Among the many reasons,the well-being of family members remained a top barrierthat influence their attitude to work during a pandemic(Ives et al., 2009). In December of 2019 and the firstquarter of 2020, the world grappled with the devastating
effect of COVID-19. Many died around the world,
including the HCPs. Moreover, it was sad to note thatduring this time of crisis, when their services were badly
needed, some of the HCPs had no recourse but to resignfrom their jobs. There were reports of HCPs leaving
their jobs, such as in Australia (Cush, 2020), UK (Boswell,2020), Bulgaria (Petkova, 2020), and other countries.
They were called the “deserters” (Pahlman, Thomo, &Gylling, 2010) for abandoning their duty. Others were on
the verge of surrendering (Boswell, 2020). Among the
major reasons were the lack of protective equipment(Boswell, 2020; Cush, 2020; Freitas, Napinoga, &Donalisio, 2020; Lancet, 2020; Skorzewska, 2020),
extended work schedules (Boswell, 2020), and the fearof passing the virus to their families (Lancet, 2020). All ofthese were valid reasons, which are expected, especiallyduring a crisis like a pandemic.
Table 1: Top 10 countries with the largest number of
HCPs’ fatality

Source: Medscape (www.medscape.com/viewarticle/927976)

Table 2: Number of HCPs infected with COVID-19 in thePhilippines

Source: DOH Televised Briefing (as of April 30, 2020); CNN
Philippines (2020b)

The COVID-19 pandemic, however, is not the firsttime when HCPs are put in a situation where they haveto make a tough decision. For example, when a report
was published about health workers being infected withAIDS due to exposure to patients’ blood, several healthprofessionals expressed apprehension of having contacts
with their patients. Dr. Terence M. Schmahl, a heart
surgeon in Milwaukee, said in an interview, “I’ve got tobe selfish. It is an incurable disease that is uniformly
fatal, and I’m certainly at a high risk of getting it”(Gruson, 1987). The COVID-19 pandemic opened up a
new threat to the HCPs. They were afraid of getting thevirus while in the hospital treating the COVID-19
positive patients. They also suffered from psychologicalstress (Simione & Gnagnarella, 2020; Wu, Styra, & Gold,
2020; Zhang, et al., 2020; Zhu et al., 2020) due to theenormous demands because of the huge number ofpatients, discrimination from society, and the thought ofcontracting the virus. Some of them are in a dilemma ifthey have to stop working or not. Are they concernedEubios Journal of Asian and International Bioethics 30(5) (June 2020)
about their safety and their families? What about thepatients who are helpless without their services?
Rational egoism
Is the decision of HCPs to leave their jobs or their refusal
to report to work ethically wrong? With the number of
HCPs infected of the virus and the fear that engulfed
other HCPs, how do we explain the ethical elucidation ofsuch a dilemma? Or, how can we explain the decision of
those who eventually resigned from their job? In Wealthof the Nations, Adam Smith wrote, “It is not from thebenevolence of the butcher, the brewer, or the baker that
we expect our dinner, but from their regard to theirinterest. We address ourselves, not to their humanity but
their self-love, and never talk to them of your necessities
but their advantages” (Smith, 2010, p. 8). The actions ofindividuals are intended for self-gain. Though theintention is of self-interest, Smith, in describing it as aninvisible hand, argues that by pursuing one’s interest, it
has an eventual effect on society. However, the maincontention here is the concern for oneself.
The concept of self-interest can be traced to rational
egoism, which can be attributed to a Russian philosopher
Nikolay Chernyshevsky. In his novel What is to Be Done,
Chernyshevsky described Lopukhov’s act to save Vera
Rozalsky from a marriage pre-decided by her tyrant
mother as a selfish act because he was in love with her.
His book became an inspiration for revolutionaries andwas credited to inspire the creation of the Soviet Union.
An English philosopher Henry Sidqwick was also
credited for rational egoism, as explained in his book The
Methods of Ethics. Agreeing to Hobbes’ concept of “Seekpeace and follow it”, Sidqwick (2017) described theprecept of rational egoism as self-preservation. He
further said, “In Spinoza’s view, the (egoistic) principleof rational action is, as Hobbes thought, the impulse of
self-preservation” (Sidqwick, 2017, p. 41). In explaining
what is reasonable conduct, he further argued that “theultimate end of each individual’s actions is his own
greatest happiness” (p. 55). However, towards the end of
his book, Sidqwick is stuck with the problem- conflict
between rational egoism and universal benevolent. This
gray area did not escape the criticisms from other
scholars (Sverdlik, 1985). In the concluding chapter, hepointed out a conflict between self-interest and duty. He
wrote, “But in the rarer cases where we ﬁnd a conﬂict
between self-interest and duty, practical reason, is being
divided against itself, would cease to be a motive on
either side. The conﬂict would have to be decided bywhich of two groups of non-rational impulses had moreforce” (p.248). The dilemma among HCPS is the tug-ofwar between personal sacrifice or duty. It can be notedthat Sidquick, throughout his book, described rational
egoism. However, he still considered finding a harmony
between the two (self-interest and duty) as problematicand is subject to more debates.
Another Russian born writer, Ayn Rand, rose to famethrough her works inspired by her objectivist
philosophy. Hes philosophy is expressed in her novels,
particularly in The Fountainhead and Atlas Shrugged.
Atlas Shrugged, first published in 1957, continued to sell
well. For example, it sold 200,000 copies in 2008,
500,000 copies in 2009, and around seven million copies
sold all in all dating back a decade ago (Jackson, 2011).

261

In an article The Guardian written by Freedland (2017),
US President Trump, some key republicans, and popular
US entrepreneurs were mentioned as some politicians
influenced by the philosophy of Rand. Alan Greenspan,
Federal Reserve chair, used Rand’s objectivism as aninspiration in his work (Weiner, 2016). However, Rand’s
philosophy became the subject of criticisms andridicules. Critics to Rand were quick to caution on thenegative connotation of her idea. According to Presley(1999), the critics of Rand, such as Lasch, Kohn, andSampson, were concerned about the consequences of
unbridled individualism (p. 256). According to Burns(2009), Rand’s biographer, it was only Aristotle thatRand acknowledged having an influence on her and she
was asked for an opinion she would refer to a characterin her novels, although in her childhood years she wasreading the works of Walter Scott and Victor Hugo. Rand
criticized altruism (renouncing oneself for the sake ofothers) as against egoism, or what he called as rationalselfishness. Hicks (2009), in discussing egoism by
Nietzsche and Rand, created a matrix showing thedifferences among altruism, selfishness, and egoism as tointent, consequence to self, and consequence to others. It
is clear that the intent of the three is different, but for theconsequence to others both Altruism and egoism
connote benefits.
However, altruism and egoism
disagree on the consequence to self.

Source: Hicks (2009). Egoism in Nietzsche and Rand, p. 256.

Aside from her novels, Rand had written a bookentitled “Selfishness as a Virtue: A New Concept ofEgoism”. The book is a collection of her essays. In the
introduction, Rand already warned readers that the title
itself may evoke questions about the irony from theaccepted concept of selfishness.
To this, Rand
immediately provided the answer- “For the reason thatmakes you afraid of it.” She recognized that the word
“selfishness” is popularly synonymous with evil oranything referring to pure self-gratification. Explaining
the social principle of objectivist ethics, Rand argues that“the achievement of his own happiness is man’s highest
moral purpose” (Rand, 1964, p. 9). The starting
argument of Rand is the definition of selfishness fromthe dictionary, which is about the concern with one’s
interests. He added that “to be selfish is to be motivatedby concern of one’s self-interest” (Rand, 1964, p. 40). In
the case of the HCPs who left their jobs, they chose thehigher value of protecting their own lives and the lives of
their families. Rand describes selfishness that includes(a.) “a hierarchy of values set by the standard of selfinterest, and (b.) the refusal to sacrifice a higher value toa lower one or to a nonvalue” (p. 40). From the patientsand their families, and even from the public, the act ofsurrender while others need their services is cowardiceand pure neglect of one’s oath. However, for the HCPs,

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their decision is based on their moral judgment, values,and convictions. Are they selfish or simply expressing
what Rand calls as genuine selfishness? Rand defines
genuine selfishness as “a genuine concern withdiscovering what is to one’s self-interest, an acceptanceof the responsibility of achieving it, a refusal ever tobetray it by acting on the blind whim, mood, impulse or
feeling of the moment, an uncompromising loyalty to
one’s judgment, convictions, and values- represents a
profound moral achievement” (p. 42). Thus, is thedecision to leave the medical practice an act of genuine
selfishness? Rand’s definition justifies such a decision.
Self-interest and Christian Ethics
Concern and love for others are the core of Christianethics. Fr. Bud Grant, a professor of theology at St.
Ambrose University, said that Catholics follow certain
legal, moral and ritual maxims of the Christian faithbecause of their desire of heaven (Grant, 2011).
Supporting this notion is equivalent to doing something
to gain something, which is heaven. However, more thanthe personal gain, the Church remains committed toproclaiming the gospel values and the commandment ofloving God and loving one’s neighbor. Jesus Christ gave
the example of sacrificing His life for the sake of others.
Similarly, the Church is consistent in its catechism with acommon theme on the common good, particularly in hersocial teachings.
Pope John Paul II, in his apostolic letter entitledCentesimus Annus, said: “All human activity takes place
within a culture and interacts with culture. For anadequate formation of a culture, the involvement of thewhole man is required, whereby he exercises his creativity,
intelligence, and knowledge of the world and of people.
Furthermore, he displays his capacity for self-control,
personal sacrifice, solidarity and readiness to promote thecommon good. Thus, the first and most important task isaccomplished within man's heart” (Paul II, 51).
The concept of self-sacrifice for the common good
explains why selfishness has no place in the Christianfaith. A genuine Christian is willing to forget oneself forthe sake of others. Hence, martyrdom is considered as
the supreme form of witnessing to the faith. Pope Francis(2016) re-affirmed the meaning of the common good “asa central and unifying principle of social ethics” (p. 156).
The pope reiterated the teachings of the Church about
the common good, that is “the sum of those conditions ofsocial life which allow social groups and their individual
members relatively thorough and ready access to theirown fulfilment” (Paul II, 1994; Paul VI, 1965). The
essence of Christianity is the common good- the concern
for others above one’s self-interest. In the gospels, Jesus
explains the greatest sacrifice, which is to die for one’s
friend.
In a practical sense, the HCPs during this COVID-19
pandemic face the threat of their lives, but they are alsocaught in between the decision to save themselves and tosave others. The ethical dilemma on their decision tocontinue or not in exercising their duties is dependent on
their philosophy in life or their faith. As Christians, thegreater good is the common good. To sacrifice for thesake of others is the ultimate vocation for each followerof Christ. In this pandemic time, the faith of the HCPs istested with fire. After all, this is about life and death.

The equalizer: lessons of the past
I have pointed out that the ethical dilemma among HCPs
during a pandemic is influenced by their philosophy inlife or faith. However, I refered to the literature to
discover what had been learned from the past
pandemics and even the lessons of the recent one. One
important lesson of the past was to look at the factorsthat influence the decision of health workers during apandemic. The most common factor is the safety of HCPs
through the strict observance of the precautionary
principle (Balicer et al., 2010; Garrett, Park, & Redlener,
2009; Gershon et al., 2010; Possami, 2007). For example,
Balicer et al. (2010) found that ensuring adequate
supplies of personal protective equipment andestablishing a subjective norm of awareness andpreparedness are among the things that influence HCPs’
willingness to report to work during a pandemic.
Moreover, Gershon et al. (2010) pointed out
organizational preparedness with an emphasis on
worker protection. And, recognizing the hassle of travels,
Ives et al. (2009) suggested to the UK health care sector
to provide accommodation and provision of informationand guidance to ensure the safety of HCPs.
On a macro level, Upshur et al. (2005) called for thegovernments and the health sector to implement acomprehensive and transparent protocol to ensure thesafety of health workers. At present with the still ongoing fight against COVID-19, there are lessons worth
mentioning. For example, Taiwan, using the lesson from
SARS, implemented a modified form of traffic control
bundling to protect its health workers (Schwartz, King, &Yen, 2020). And, based on the experience, in Wuhan,
China, there was also a suggestion for a provision of
periodic professional development among HCPs in theprotection from occupational hazards (Zhang et al.,2020). Also, Adams and Walls (2020) recommended
letting the workers feel that they get enough rest as partof the supporting mechanisms. Moreover, healthcare
managers need to address the mental health of HCPs
(Greenberg, Docherty, Gnanapragasam, & Wessely,2020). The question is, have we learned from the pastlessons? According to Dr. David S. Jones, in his article
entitled History in a Crisis- Lessons for Covid-19, “thehistory of epidemics offers considerable advice, but only
if people know the history and respond with wisdom”(Jones, 2020). What is clear from the past and present
lessons is ensuring the safety of HCPs. Their decision
during a pandemic largely depends on how thegovernment and the institutions they are working canprovide protection. I argue that, regardless of beliefs andfaith, HCPs are faithful to their calling, but they should beaccorded with respect and protection for them not to beplaced in a situation where they are confronted with the
ethical dilemma as to their decision to serve or not.
Conclusion
From the philosophical point of rational egoism, thedilemma about the decision of HCPs is justified by theirself-interest, whom Rand calls it as rational egoism.
When their decision is well-thought influenced by soundjudgment, their convictions, and values, it is genuine
selfishness, as Rand’s describes it. However, if thedecision is based on one’s Christian faith, the notion ofEubios Journal of Asian and International Bioethics 30(5) (June 2020)
the common good surpasses one’s self-interest. In otherwords, the ethical dilemma among HCPs can be gleaned
from two lenses- rational egoism and Christian ethics.
For those who are confused but are leaning towards
surrendering or those who take the crucial decision ofleaving the profession, they decide based on thephilosophy of rational egoism. For those who remain
and continue their mission as health workers, theydecide based on their faith, particularly on the principleof the common good. However, before any philosophicaland faith-related justifications, HCPs, by virtue of theiroath, are willing to serve as long as the government or
health institutions provide an assurance of their safety.
It is not worth risking one’s life when protective
equipment and other supporting mechanisms are notprovided. Thus, hospitals and any other healthcare
institutions need to prepare and to implement
precautionary measures to ensure the safety of their
HCPs.
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Fontiers of Medicine, 1-3. https://doi.org/10.1007/s11684020-0765-x

of social relations where recognition stands as atheoretical framework. 11 An affirmative standpoint istaken and the basis for this assertion is articulated
through an explanation of what social (in)justice consists
in based on the theory of recognition where man’s
relation with the environment is re-appraised from theviewpoint of intersubjectivity. Within this viewpoint theenvironment is described as always already integrated in
the everyday zones of practical human affairs whichmake it therefore a concern of social theory.
Reconstructing Axel Honneth’s social theory, recognition
is presented here as the holistic and fundamental
condition for the flourishing of persons’ full integrity inwhich the environment forms an integral part of theirwell-being. Any response that deviates from this would
constitute reification described more fully, in the second
part of the paper, as the loss of the empathetic
engagement with the environment. This loss is theparticular forgetfulness of recognition in the dimensionof man’s relation with nature which is traced, via
normative reconstruction, from the emergence of theArne Johan Vetlesen remarks that “the environment is notamong the topics with which critical theory is commonly
associated.” Arne Johan Vetlesen, “Critical Theory and theEnvironment,” In Routledge Companion to the Frankfurt School(New York: Routledge, 2019), 471. Vetlesen ascribes to thethree generations of critical theorists the increasing
disappearance of the place of nature in their theory. He claims
that from Theodor Adorno to Axel Honneth, critical theory
suffers from a “nature deficit” in their lack of a direct treatmentof the relation between man and his environment. See Arne
Johan Vetlesen, The Denial of Nature: Environmental Philosophy
in the Era of Global Capitalism (London: Routledge, 2015). An
eloquent and incisive critique of Honneth’s early social theory
follows this same line of criticism by Jean Philippe Deranty. He
argues that “the model of interaction that has gradually
emerged as the fundamental structure upon which the ethics ofrecognition is built, is restricted to intersubjectivity narrowlyinterpreted as interhuman interpersonality” (Italics mine).
Jean-Philippe Deranty, “The Loss of Nature in Axel Honneth’s
Theory of Recognition. Rereading Mead with Merleau-Ponty,”
Critical Horizons 6 (2005): 164. The ramifications of this loss ofnature according to him is that the ethics of recognition puts
the duty towards nature indirectly and is featured relevant
only within the context of its value to the fulfilment ofsocialized individuals. The implied premise for this observationis that recognition, reduced to intersubjective interaction
cannot account for a critical articulation of man’s relation withnature and his environment. As Deranty bemoans “it seems
difficult to use the ethics of recognition to account for the
feelings of wrong and even injustice that human beings feel on
the part of desecrated natural sites, tortured, massacred orindustrially exploited animals.” Ibid., 168. But despite theperspicacity of Deranty’s critique, it would be excessive toclaim that Honneth’s social theory excludes the relation
between persons and the world of nature though, Honneth
himself admits that nature recedes into the background of thesocial which is primarily the object of his study. For nature, as
Honneth conceived, is supposed to be integrated already rather
than lost in the everyday practical aspects of social life. Whatarises, in fact, are anomies in the harmonious relation between
man and his environment—social pathologies which thencould be diagnosed via critique. From the theoreticalstandpoint of recognition therefore, the environment is a socialand moral concern which demands a responsive practicalaction. This paper counters therefore both Vetlesen and
Deranty’s standpoint.
11

Axel Honneth on social justice and theenvironment as a moral-practical concern-Victor John M. Loquias
Graduate School, University of Santo Tomas Manila, Philippines
Philosophy Department, Ateneo de Naga University
Email: vloquias@gbox.adnu.edu.ph“The earth,’ he said, ‘has a skin; and his skin has diseases. One ofthese diseases for example is called: ‘Human being.’” – Friedrich
Nietzsche (2006)

Abstract
An environmental ethics grounded on a theory ofrecognition assumes social justice as incomplete without
the due recognition of persons’ relationship with theenvironment from the standpoint of well-being as anintegral part of human flourishing. The state in which
this recognition is found missing in intersubjective
relations is called reification or the loss of theempathetic engagement of persons with theenvironment. In Axel Honneth’s social theory, thehistorical moment in which this reification began can betraced from the emergence of the capitalist economic
system. Economic inequalities and environmental crises
are simultaneous effects of capitalism symptomatic of
the severed empathetic engagement with theenvironment. The ethical significance of the environmentis derived therefore on the first place from its role in the
moral integrity of persons. The environment becomes a
critical concern for social critique in the advent of thisreification. Ethical action towards the environment in arecognitive framework demands reparation of thisempathetic engagement in the practical level of humanaffairs where the environment is always alreadyintegrated.
Introduction
This paper answers the basic question whether anenvironmental ethics can be drawn from the normativity

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
capitalist economic system. Capitalism described as misdevelopment of the institution of the market economy isidentified likewise as the historical moment in which theenvironment assumed a critical concern for social
critique. Ethical action towards the environment
assumed its significance on the first place because it isintegral to the moral integrity of persons. Global
environmental crises however is symptomatic of thissevered empathetic engagement with the environment,
the reparation of which calls for practical action. The
third part therefore where the environment is framed asa moral-practical concern joins together how theenvironment takes on significance within a recognitive
stance. It is moral because personal integrity isdependent on the recognition of the relation with theenvironment as an integral part of a flourishing life, andpractical because social critique elevates theenvironment to a demand for ethical action against
disrespect or reification situated in the spheres ofrecognition or the institutions of social freedom. Ethicalaction towards the environment must therefore be
localized in these institutions for more efficiency andparticularity where engagement with the environment isfound in varied human affairs. The features of anenvironmental ethics within the framework of social
recognition is outlined afterwards.
What is social (in)justice?
Social injustice is foremost the normative basis for social
critique. In Axel Honneth’s theory this is consistently
maintained from his early works12 where the theory ofrecognition takes centre stage up to his later focus on thehistoricality of forms of recognition into the social
institutions of freedom.13 As in the composite descriptionof Heikki Ikaheimo, recognition in the context of thesocial dimension of existence serves both as an
ontological and ethical foundation. Ontological because
the coming to be of subjects as persons happen via
mutual recognition. It is ethical as well because theextent of recognition rendered and received by persons
determines how close they come to the good life which
ought to be reached by them as persons.14 Honneth’s
proximity to Aristotelian ethics is obvious here in the
teleology of human act to a flourishing life. The Kantian
principle is also manifest in that, a flourishing life isdeemed universally achievable by all rational beings.15

12 See Axel Honneth, The Struggle for Recognition: The Moral

Grammar of Social Conflicts, Translated by Joel Anderson(Cambridge: Polity Press, 1995); and Axel Honneth, Disrespect:
The Normative Foundation of Critical Theory, Translated byJohn Farell (Cambridge: Polity Press, 2007).
13 See Axel Honneth, Freedom’s Right: The Social Foundations of
Democratic Life, Translated by Joseph Ganahl (Cambridge:
Polity Press, 2014).
14 Heikki Ikaheimo, “Making the Best of what We Are:
Recognition as an Ontological and Ethical Concept” in The
Philosophy of Social Recognition: Historical and Contemporary
Perspectives,” Edited by HansCristoph Schmidt am Busch andChristopher F. Zurn (Plymouth, Lexington Books: 2010), 346.
15 A similar mix of this Aristotelian and Kantian principles isarticulated by Daryl Macer which he applies to groundbioethics. He writes: “An Asia-Pacific perspective of bioethics
would say that the pursuit of a good life is a goal that all265

But beyond Aristotle and Kant, Honneth takes a Hegelianinspired rendition of the development of persons
grounded on intersubjectivity. The ethical life
(Sittlichkeit) for Hegel is achieved through a series of
struggles for recognition that progressively integrates
individuals into the social spheres of the family, civilsociety and the state which are formed out of theagonistic process itself. The subject therefore is nolonger conceived as an atomistic entity that could
achieve self-realisation alone or determined blindly byfactors external to his will because the individual and thesocial come together, in the original language of Hegel’s
philosophy, as objectification of the spirit.16
Taking a naturalistic turn via Georg Herbert Mead’ssocial psychology, Honneth revises Hegel’s ethical life
into the spheres of recognition that contribute to thepsychological development of the identity of persons.
This identity formation is a life-long process ofsocialization where subjects progressively gain positivemodes of relating-to- self through recognition accorded
to each other. The progress made is gauged according to
the proximity that individuation reaches greater
integration, the deficit of which indicates moving awayfrom its course. The struggle for recognition is the
ontological condition for this becoming social ofindividual subjects that Honneth arranges into three
general spheres.
Foremost is the recognition received in the sphere oflove and care that caters to the basic need for emotional
development necessary for an individual to grow in
independence. Having the initial experience of being
affirmed singularly as an individual subject, a person
learns self-confidence which enables him to carry out thegreater struggles ahead in life. This sphere however isquite limited only to persons within the range of
intimacy from whom love and care could be expected formutual reciprocation. The second sphere in contrast
demands recognition of persons as entitled to rights, afeature that one shares with the rest of his fellowman asa bearer of dignity. This is the sphere of equality whichmust be accorded to every individual through legislationand execution of laws having wider, universal reach. So
endowed, the individual gains self-respect which enables
him to view himself as a citizen equally entitled to rightsthat should be promoted. In the third sphere a person isrecognized in his particularity as part of a community
who could contribute to its development. Such
recognition naturally elicits self-esteem in persons fortheir unique capabilities that could render service invarious ways to the society. It also empowers them suchthat it allows them to take an agentive role to work insolidarity with the rest of the members of the society.17
These spheres constitute the normative conditions
for the moral development of persons and thepsychological progress of a well-rounded personality. A
recognition grounded morality takes socialization as the
persons can hope for.” Daryl Macer, PHILIPPINIANA SACRA
47/140 (Special Issue, 2012): 455.
16 See Georg Wilhelm Friedrich Hegel, Lectures on Natural Right
and Political Science The First Philosophy of Right, Translated by
J.M. Stewart & P. C Hodgon. (Berkeley: University of California
Press, 1995).
17 Honneth, The Struggle for Recognition, 92-130.

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condition for practical action that approximates the goodlife. What this take on morality immediately implies isthat the good life, being intersubjective in nature, always
entails having to respond to what is due to the other, ofjustice in other words. In this context, what is due refers
to the recognition that ought to be rendered to the other.
For Honneth, justice cannot be determined beforehand
as a normative universal principle which could later beapplied in particular circumstances. Justice takes various
forms according to the normative demands ofrecognition that shape culture specific values and norms
in the society. The three spheres of recognition identified
by Honneth therefore presuppose as well three forms ofjustice that respectively contribute to the moral
development of the individual.
To determine what is just implies then an antecedentknowledge of justice which becomes crystal clear
especially when one experiences having been denied or
deprived of them. Injustice occurs when recognition iswithheld from persons and wounds up the personality,
disabling the ascent of the individual to greater social
integration. Rape and torture are concrete examples ofinjustices in the sphere of care; unjust wages would beinstances of disrespect in the second sphere where theright for just compensation of one’s labour andachievement is disregarded for profit making;humiliation and social denigration on the other hand areclear acts in the third sphere which disempower
individuals and their capability to contribute to social
development and change. Elsewhere, 18 these acts ofmisrecognition are also categorized by Honneth under
the concept of “pathologies,” a medical term that refers
to illnesses but also implies the procedural course for its
remedy—diagnosis. While pathology metaphorically
captures the experiences of social misrecognition,
diagnosis illustrates on the other hand the role of social
critique in disclosing these aberrations so as to identify
the right social therapeutic measures in regaining
psychological and social health.
While Honneth tackles recognition in the context ofidentity formation, he later admits shifting the emphasis
on its institutionality so that the spheres may be taken tomean already as “social goods.”19 This shift is premisedon Honneth’s insight that recognition takes on different
forms in different historical conditions. Overtime they
are institutionalized in relative social environments. In
as much as recognition allows for self-realization, we
could also say that it is the course through which one
becomes free—in the society where one is socialized.
Socialization in this case would be the condition of
freedom. While the progress of identity formation
follows the ascent towards greater degrees ofrecognition, freedom in turn is fulfilled in greater
participation with social institutions. These institutions
normatively at work today are (1) personal relationships
which include the family, friendship and intimate
relationships, (2) the institution of market economy, and18 Honneth,

Disrespect: The Normative Foundation of Critical
Theory.
19 See Morten Raffnsøe-Møller, “Freedom, Solidarity, and
Democracy: An Interview with Axel Honneth,” In Recognition
and Freedom. Axel Honneth’s Political Thought, Edited by Odin
Lysaker & Jonas Jakobsen (Leiden: Brill, 2015).

(3) democratic political will-formation. Social freedom
consequently is the individual’s being integrated into
these social institutions. The society on the other hand,zoomed in, illustrates an organically comprised wholethrough the confluence of these institutions which
Honneth describes as the substance of a democratic
ethical life—an obviously reworked Hegelian notion of
the ethical life in the present.20
Participation in these social institutions presuppose
self-realization in each respective domains. Justicetherefore is served already in these institutions for, as
Honneth states, “what we can reasonably call ‘justice’
today is largely contained in the normative principles
that underlie and lend legitimacy to the constitutive
spheres of action in our societies.” (Willig, 2012, p.147).
Injustices on the other hand would take form in themisdevelopments, earlier described also as pathologies,of these institutions. Hence, the need for social critique.
The task of social critique is also at the same time thework which justice performs as “analysis.” 21 For
Honneth, this means internal critique or normative
reconstruction22 of norms and values originally bent
towards emancipation. Justice as analysis refers to thetask of judging questions of legitimacy of these values.23
Zurn (2015, p.14) attributes this method to a
Nietszchean influence in Honneth so that we could also
call it as revaluation of “meanings, interpretations, andvalues in order to change institutions and practices.”
Honneth’s focus on the social gives the impression oftaking for granted the concern with nature and theenvironment, that it lies outside the scope of social
critique. Honneth (1991, p. xxi) admits letting “the aspectof the social relation to the natural world remain too far
in the background” of his work of “establishing the
suppressed dimension of conflictual interaction within the
tradition of critical theory." But whether it is of social
critique to address, Honneth has very early affirmed it in
the positive. The following statement of Honneth
provides an early support for the claim in this paper thatthe environment takes on a moral-practical concern:
A social theory whose central concern is to treat thepractical relationship to inner and outer nature as abasic fact of forms of social life, however, must inquire
about the access to precisely these everyday zones ofsocial action. That is, the cultural models that aredecisive within a society for organizing and regulating as
a whole the exchange with the natural world arepresented not within the sphere of aesthetic production,
which has in the meantime become autonomous, but
within the specific spheres of institutionalized everyday
action. Practices concerning the preparation of food andthe rearing of children, the cultivation of nature, and
20 SeeHonneth, Freedom’s Right: The Social Foundations of
Democratic Life
21 Honneth, Freedom’s Right: The Social Foundations of
Democratic Life, 1-11.
22 Honneth describes this as disclosure of the institutionalized
normative ideas and principles informing our practices though
they may not be immediately transparent to us. Gonçalo
Marcelo. “Recognition and Critical Theory Today: An Interview
with Axel Honneth.” Philosophy and Social Criticism 39:2
(January 2013), 216, DOI: 10.1177/0191453712470361.
23 Honneth, Freedom’s Right: The Social Foundations of
Democratic Life, 58.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
one's relationship to one's own body present domains ofaction of this sort in which the social relationship tonature is daily reproduced. The normative practical rulesthat in turn guide these cultural activities can then be
distinguished according to the question of whether they
are more "mimetically" compliant or "instrumentally"
controlling in their relation to the natural environment.24
Here, Honneth is advancing his critique of Theodor
Adorno’s relocation of the “mimetic”25 relation to thenatural world within aesthetic production. Honneth
apparently sides with the non-instrumental mode ofrelating with nature that Adorno and Horkheimer
advances against the enlightenment’s rationality of thedomination of nature. But Honneth does not see it
fruitful for a critical social theory within the redemption
offered by Adorno in art and aesthetic production. Itshould be found rather in the critique of everyday
practical social life that forms the society’s cultural
habits. This means that for Honneth, nature is integrated
already, and not lost, in the everyday life of man. Yet he
was quick to acknowledge that the Frankfurt School
tradition offers less elaboration in this matter thanFrench social anthropology mentioning specifically theworks of Claude Levi-Strauss.26
Honneth identifies that in relation to nature “thedanger of a social pathology emerges when nature isdominated to such an extent that the very possibility of anonviolent integration of nature into the practice ofsocial life is inhibited.”27 In Honneth’s reading, LeviStrauss’ ethnographic works shares an affinity with Jean
Jacques Rousseau in the latter’s diagnosis of modernity.
“Ethnography is justified as an empirical science ofarchaic cultures by the experience of estrangement fromnature characteristic of modern societies.”(p. 140) In its
reconstruction of theoretical models from archaicsocieties, where it could still find intact the “feeling ofsolidarity and primordial accord with every natural life
form as the fundamental ‘principle’ of all social life,” (p.
148) ethnography could offer an empirically grounded
corrective guidance for rebuilding society. This time asociety based on an expanded view of freedom
reconciled with the ecological ethics of the “integrationof all social life with the natural world.”28
What Strauss’ enterprise represents is a diagnosis in
one of the three regions of possible failure in social
development, these three regions being: with regard to
an individual’s relation to self, with regard to therelations of social life and with regard to the relation tonature.29 While the domination of nature accounts for
24 Ibid.

25 Mimesis

refers to the human cognitive activity in which“thought makes the world resemble itself.” Theodor Adorno
and Max Horkheimer, Dialectic of Enlightenment, Translated by
Edmund Jephcott (California: Stanford University Press, 2002),
19.
26 He also mentioned Johann P. Arnason and Klaus Eder tobelong to the same category of interweaving the social with therelationship with the natural.
27 Axel Honneth, “Author’s Introduction,” In The Fragmented
World of the Social: Essays in Social and Political Philosophy,
Edited by Charles W. Wright (Albany: State University of New
York, 1995), xxi.
28 Ibid.
29 Axel Honneth, “Author’s Introduction,” xxi267

the pathology in the third aspect, the disintegration ofidentity in the first and second region results from either
the dominance of individuality or collective identity to
the exclusion of each other. Honneth takes up again
more thematically this dimension of man’s pathologicalrelation with nature in his reconstruction of Georg
Lukacs’ concept of reification. Honneth (2008, p.66)
states that likewise, there are three forms of reification:“reification in our relationship to other people, in our
relation to nature, and in our relation to ourselves.” If thethree forms of a positive relating-to-self are to beunderstood as “normative or ethical ideals” which
reification is able to penetrate, reification can be judged
therefore as a “problematic deviation” from each
respectively. In the next part, the relation to nature will
be shown as an integral aspect of a positive relation toself which is nonetheless withheld in the process ofreification described by Honneth as forgetfulness of thefundamental act of recognition. This will eventuallyshow that social (in)justice as described above is linked
with man’s relation with the natural world and social
emancipation is unattainable without the recognition of
the environment as an integral part of humanflourishing.
Reification as the loss of empathetic engagement
Honneth’s distinction of the three forms of reification
presupposes the holistic status of recognitioninterweaving the relation that the self has with himself,others and nature, so that a fully realized existence
cannot not be deficient in any of these three aspects. For
Honneth reification indicates “the process by which welose the consciousness of the degree to which we owe
our knowledge and cognition of other persons to anantecedent stance of empathetic engagement andrecognition” (Italics mine, p. 56). Put differently, it is theloss of this empathetic engagement which is “theprimordial form of relating with the world. (p.37).” In
this state individuals tend to perceive others as mere
things, which means that the observable behaviouralexpressions of others are not perceived with that claim
for recognition and demand for appropriate response.
Honneth likens this further to “the autistic child’s worldof perception, as a totality of merely observable objects
lacking all psychic impulse or emotion.”30 Here, not onlythat a fundamental connection is missing between
persons, but objects as well which are accorded values
by individuals are neutralized in the sense that they aretreated as mere things devoid of values and meanings
attached. But the antecedent recognition of persons
which Honneth refers to demands that objects should
not be perceived apart from the contexts that persons
respectively attach to it.31 What Honneth is saying here
obviously is that in recognition, the social and theobjective natural world converge integrally that arupture between can only result into reification.
Honneth’s turn to Adorno in advancing the noninstrumental treatment of nature as the non-reified formof relating with nature shows only the holistic characterof intersubjective recognition. This is even more audiblein Honneth’s words:
30 Ibid., 58.
31 Ibid., 63.

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With Adorno, we could add that this antecedent
recognition also means respecting those aspects ofmeaning in an object that human beings accord that
object. If it is indeed the case that in recognizing otherpersons we must at the same time recognize theirsubjective conceptions and feelings about nonhumanobjects, then we could also speak without hesitation of apotential “reiﬁcation” of nature. It would consist in ourfailing to be attentive in the course of our cognition of
objects to all the additional aspects of meaning accorded
to them by other persons. Just as is the case with thereification of other persons, a “certain blindness” is here
at hand. We then perceive animals, plants, or things in amerely objectively identifying way, without being awarethat these objects possess a multiplicity of existential
meanings for the people around us.32
The meanings and values that persons attach tothings indicate their capacity to live a life where theworld becomes integrated into a certain view of aflourishing life or well-being. The term “environmental
identity” which Figueroa defines as “the amalgamation ofcultural identities, ways of life, and self-perceptions thatare connected to a given group’s physical environment”33
aptly describes man’s inseparability with his
environment. This entails that disrespect, consisting ofactions that wound up the personality in the spheres ofcare, rights and solidarity, implicates as well how anindividual is treated in his fundamental way of living in
the world from the standpoint of well-being. Whatevercounteracts this fundamental orientation to life may be
categorized under reification. And it is interesting that
Adorno’s interfacing description of “the wrong state ofthings” (Adorno, 2004, p.11) and “damaged life”(Adorno, 2005, p. 120, 193-4) all lead to that one
historical phenomenon which may be identified as theprime reason for having the environment take on such a
critical concern today to be addressed—capitalism.
Adorno (2005)’s analysis, for Honneth (2005) is “not an
explanatory theory but a hermeneutic of a failed form oflife,” a genealogical interpretation of “the rise of oursecond nature in the reified, frozen life conditions
established by capitalism.” Damaged life includes
reification of nature which is most exemplified today by
disrespected indigenous modes of life and theindigenous peoples’ deterritorialization from theirhabitat through massive environmental destruction to
the interest of life indifferent capitalists.
Once the notion of reification is understood toinclude forgetfulness of man’s self-determination in his
mode of relating with his environment from the context
of well-being, the environment appears now more
prominently as a political and cultural concern. Andre
Gorz’s framing of the environment as ecology isparticularly helpful in reinforcing this claim. Gorz
corroborates the fact that reification of the capitalist
system is that which puts forth the critical concern
between man and nature. He dispels the pretence that
32 Ibid.

33 Robert Melchior Figueroa, “Indigenous Peoples and Cultural

Losses,” In The Oxford Handbook of Climate Change and Society,
Edited by John S, Dryzek, Richard B. Norgaard, and David
Schlosberg (New York: Oxford University Press, 2012.), 2,
DOI:10.101093/oxfordhb/9780199566600.003.0016.

ecology is apolitically self-sufficient, and that it isespecially concerned with man’s “return” to naturereconceived as sacred. “The ecological movement is not
an end in itself,” he says “but a stage in the larger
struggle.” (Gorz, 1980, p.3). He was referring to themonolithic struggle against capitalism confronting thesociety in a global scale. Capitalism is propelled by theideology of growth which, it insists, is inexhaustible innature thus justifying the endless consumption mediatedby labour. Yet on the contrary, science and technology
according to Gorz (1980) has already established that“all productive activity depends on borrowing from thefinite resources of the planet and on organizing a set of
exchanges within a fragile system of multiple
equilibriums.” Ecology, or what he terms as “ecologicalrealism,” is a critique of this growth-oriented capitalism
by unveiling this suppressed fact of the external limits tohuman activity in the natural world. The effects of theutter disregard of this limits has long manifested alreadyin the globally experienced catastrophes, diseases ofcivilization and reduced quality of life despite the highlevels of material consumption.
Gorz, in other words, diagnoses the social genesis ofenvironmental reification where it becomes an object ofsocial critique. For Andre Gorz, ecology stands in relation
with the emergence of political economy. It is the antithesis immediately confronted with “economic
rationality” that essentially stems from human social
activity. Writing in reference to Marx, he explains that“political economy begins only where free cooperation
and reciprocity cease. It begins only with social
production, i.e. production founded upon a social divisionof labor and regulated by mechanisms external to thewill and consciousness of individuals—by market
processes or by central planning (or by both).” (p. 14).
On the other hand, “ecology does not appear as aseparate discipline until economic activity destroys orpermanently disturbs the environment and, in so doing,
compromises the pursuit of economic activity itself, or
significantly changes its conditions. Ecology is concernedwith the external limits which economic activity must
respect so as to avoid producing effects contrary to its
aims or incompatible with its continuation.” (p. 15)”. Leftto themselves, individuals within a small community
who organize themselves autonomously and exchange
their goods and mutual services in the spirit of freecooperation needs no external intervention (for the
management of their resources) by political economy. In
so far as communities and its mode of production do notpose destructive effects to the environment, Gorz insists,
ecology as a separate science does not apply to them.
Gorz’s description of the genesis of political economy
and ecology as a science strongly corroborates
Honneth’s diagnosis of the de-socialization of the market
in the advent of capitalism: “the historical moment inwhich the capitalist economic system emerged was when
the processes of production and consumption required
for the material reproduction of society could become so
exclusively determined by supply and demand—with thehelp of the universal means of exchange, i.e. money—
that these processes could take place independent of all
normative expectations and moral consideration,

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
without any ethical embedding.” 34 Capitalism is amisdevelopment that led to the disappearance of themoral content of the market as a system of cooperation.
It has inculcated that since the economy is anonymously
propelled by blind forces, anyone can compete forindividual prosperity and grow their interest with sky as
the limit through the use of “ingenuity.”35 In other words,
the market in the capitalist system has ensured thepromise of individual freedom for private concerns.
What Honneth calls empathetic engagement with theworld was lost in this channelling of market mediatedlabour to mere individual success. Not only was cold
indifference practiced to fellow human beings’ labour infavour of profit in entrepreneurial decision making but
more so to the environment from where the resources
for production are mined. It is now manifest that thereification of the institution of market economy issimultaneous with the reification of nature.
Today, ideas of justice that revolve around theprinciple of distribution appears to draw its legitimacy
from the experience of inequality that was brought about
by capitalism. However, it can be seen now that
economic inequalities that distribution seeks to address
could still be traced from a prior fundamental act of awithheld recognition in which capitalism is both an
offshoot and the prime obstacle for its coming into theconsciousness of subjects. Capitalism as a reified
condition is a forgetfulness of the fact that the market
economy is supposed to be a social institution thatshould advance freedom in the aspect of material
reproduction through social cooperation. The rationality
it has inculcated—that the market economy is a private
enterprise—has been deeply imbedded as an economic
culture thus making it resistant to change. But the graveconsequence of this enculturation is the sustained
reduction to invisibility of diverse environmental
identities through massive and limitless exploitation ofenvironmental resources in order to keep the one
dimensional system of capitalism running. “Invisibility”
is another of Honneth’s concept which he uses in orderto describe the intentional act of not ascribing “worth” toothers as being able “to lead their lives in rational selfdetermination.”36 Capitalism as reification is not only thecause of cultural invisibility but worse, it is the cause of
the destruction of the environment and “environmental
heritage.”37
Honneth, Freedom’s Right: The Social Foundations of
Democratic Life, 178.
35 “To be a master of the economy takes the instincts of genius.”
Max Horkheimer, “Authority and the Family,” In Critical Theory:
Selected Essays (New York: Continuum, 2002), 79. Horkheimer
was describing here the invaluable characteristics of anentrepreneur regarded in a free-trade economy to stay on topof the heap. This includes the knowledge of market forces andhuman needs in order to identify what to produce, create anefficient combination of human labor and machinery to
maximize results with low expenditures and the capacity tocarry out difficult and cold decisions to increase profit.
36 Axel Honneth and Avishai Margalit, “Invisibility: On the
Epistemology of Recognition,” Proceedings of the AristotelianSociety 75 (2001), 122.
37 “Environmental heritage pertains to the meanings andsymbols of the past that frame values, practices, and places
peoples wish to preserve as members of a community.
34

269

What is done in this part is a normative
reconstruction of the emergence of the environment as a
critical concern. Capitalism is a socio-economic andhistorical pathology that has caused world-wide
environmental crises. Making sense of Nietzsche’s
description of man as a disease, today’s environmental
crises is brought about by man through a socio-economic
system which deviated from the promise of social
freedom, a pathological system now autonomously
operating and rapidly manifesting as turning against
man himself in the impending world catastrophes causedby environmental destruction. While it is possible thatnature might just cleanse itself of the disease that is man,the prevention of total annihilation is just as well a
responsibility that man must carry out through thereparation of damage which he has incurred upon
himself. The demand for social justice is a demand for“environmental justice.” 38 What is happening in ourenvironment is largely attributable to man’s doing sothat “we can no longer look out at nature without looking
back at ourselves.” (DryzecK, 2003, p. 114). The
environment which has now become a critical issue is for
man a moral-practical concern.
The environment as a moral-practical concern
Shannon Brincat (2015) articulates certain questions
that pose the urgency of recognition as a theoreticalresource, structuring the environment as a moralpractical concern. He asks: “how can communities
maintain their unique identities in the context of climatechange? How can individuals flourish amid the projectedcrises of rising sea levels, ocean acidification, declining
food production, changes to the water cycle, among
others?” (p. 278). Climate change is a global
environmental concern that demands action also in a
global scale but Brincat explains that it “cannot be
addressed without, at the same time, addressing the global
issues of inequality and uneven development that has
underpinned the crises—that is, without bringing in
cultural, symbolic, and social forces that are equally
responsible for, and causative of, climate change.”
Brincat’s identification of climate change as “part of amultifaceted crises of human intersubjectivity”39 is a
specific instance where the environment emerges as amatter for social critique.
Morality in Honneth (1997, p. 28)’s definition is “thequintessence of the attitudes we are mutually obligated toadopt in order to secure jointly the conditions of ourpersonal integrity.” Furthermore, “the various attitudes,
Environmental heritage is the expression of an environmental
identity in relation to the community viewed over time.”
Figueroa, “Indigenous Peoples and Cultural Losses,” 2.
38 “Environmental justice is broadly construed as theconceptual connections, causal relationships, and strong
correlations that exist between environmental issues andsocial justice. Environmental justice frames social issues(including cultural contexts and political economies) as
environmental issues. Social and environmental issues are
inseparable, co-causally related, and always in a context that
requires a political interpretation; in particular, such aconsideration of justice accounts for power dynamics andsocio-environmental practices that maintain historical
relations, as well as the remedies for injustices.” Ibid.
39 Ibid., 279.

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Eubios Journal of Asian and International Bioethics 30(5) (June 2020)

which taken together take up the moral point of view, areintroduced with reference to a state that is considereddesirable because it serves human well-being.” This time
personal integrity has now been established to be
inseparable from man’s mode of living and relating withhis environment. Man’s relation with the environment ismeshed with the various fields of human action. The
environment as a moral-practical concern demands that
we recognize others as making claims on us in theirpursuit of a flourishing life and that we respond inaffirmation of it through our actions in different levels. In
the case of personal relationships for example, love
becomes more concrete when we provide fornourishment of our loved ones, spend quality time withthem through vacation in the beach or by nature
tripping. Love and care for our beloved if placed in a longterm deal would take into consideration the means ofpreserving the environmental conditions that would
ensure their physical well-being.
In the aspect of labour and market economy, it has
been more evidently shown that capitalism as a social
pathology has caused environmental crises affecting the
lives of people around the world especially those indeveloping countries who are not equipped with thesophistications to deal with imminent environmental
catastrophes. Action in this sphere does not necessarily
ask for the immediate radical abolition of capitalism as it
is in fact an unrealistic project to pursue at the moment.
But the consciousness of the negative impact of
capitalism to the environment should make us initiate
alternatives for a more “socialized”40 economic market
system where social cooperation, inclusion andparticipation replace the rationality of profit
accumulation and monopoly. A more socialized market
cannot but recognize the rights of every person for
physical well-being and thus respect what Gorz earlier
stated as “the external limits” of economic activity
mediated by labour. In other words not only will the
dignity of human labour be accorded with respect butthat labour itself will also have to be respectful of theenvironment from where it gets the material for
production in order to be truly faithful to the welfare ofman in the long run which human labour serves on thefirst place. In retrospect Honneth’s agreement with
Adorno of the non-instrumental mode of relating withnature is contextualized in the latter’s critique of thefunctionalist-instrumentalist rationality of capitalism
which is a reified condition. A non-reified state, in
Honneth’s revision, would then be a reintegration of theenvironment into the context of personal integrity andwell-being. This entails a total reorientation of how werelate with each other in a more respectful manner in the
different areas wherein the environment is always
already involved—in personal relationships, work, andpolitical relations.
In democratic will formation, care for theenvironment can be better integrated when we take into
consideration the “wisdom of strangers” as Sheila
Jasanof rightly puts it. What she meant was that “others’
judgement, not our own, lays the groundwork for any
collective decisions in the modern world.” (Jasanoff,2012). Earlier the sphere of solidarity was discussed as
the recognition of persons in their capability tocontribute to the development of the society. Elsewhere,
Honneth (2017.p.62) likewise affirmed that “whereverbarriers to communication are removed, the ability of
the community to perceive as many of the currently
hidden potentials for solving a problem productively willgrow.” This entails reintegrating those who havepreviously been rendered invisible in the society to berecognized as part of decision making. Political decision
making in matters of environmental concern, as further
explained by Jasanoff (2012), needs to take into
consideration diverse perspectives. “Public reasoning, a
process that all democratic societies are committed to in
avoidance of arbitrary power, depends on prior criteriaof what counts as valid reason.” This validity springs
from the culturally specific norms and values which
varies from one culture to another. This “deep-seatedways of knowing and acting” is also called by Jasanoff as“civic epistemologies.” Jasanoff (2012).
Scientific truths are valuable for the grounding ofpolicies on facts. But interestingly, even scientific facts
established by the concerted efforts of scientists,scientists who arrive at a convergence of understandingof the facts, do not immediately reach public assent,
posing therefore an even greater challenge to reachconsensus. Jasanof (2012) points out that “factors
conditioning the reception and uptake of scientific claims
by lay publics operate to some extent independently ofthe dynamics of knowledge production within scientificcommunities.” The tendency of people when faced withsuch facts which do not “speak” in their “language” iscollective resistance or “cultural denial.” (Norgaard,2015). One reason for this is that “trust and credibility,
as social achievements, are necessarily inflected byculture, markers of trustworthiness depend on contexts
of interpretation.” (Jasanof, 2012, p.2) The tendency incertain cultures to resist change is due to the norms andvalues which preserve the cohesion of theircommunities. An example is the denial of climate change
despite having it long been factually identified byscience. In Norgaard’s description this cultural denial ofclimate change happen when “people collectively holdinformation about global warming at arm’s length byfollowing established cultural norms about what to pay
attention to, feel, talk, and think about in different
contexts.41 In a way the culture serves as a haven for thethought that everything is fine within their boundaries.
Collective action is therefore crippled and a wider
participation for political deliberation and praxis issuspended.
Cultural denial presupposes that man’s relationshipwith nature and the environment has always been
cultural. As already described by Honneth in the longquote in the first part of this paper, the relation with thenatural world is presented in the institutionalized
spheres of everyday social action. There is a need
therefore to mediate and translate scientific truths into
these diverse civic epistemologies not merely to win
their allegiance to policies but to truly pave the way for
their active engagement and inclusion in decision

Honneth, Freedom’s Right: The Social Foundations of
Democratic Life.

41 Norgaard, “Climate Denial: Emotion, Psychology, Culture, and40

Political Economy,” 7.

Eubios Journal of Asian and International Bioethics 30(5) (June 2020)
making processes. But persons also need to assess theircultural backgrounds in the face of critical issues andtheir exposure to other thought systems to effecttransformation from within and perhaps devise cultural
means for greater participation in political willformation. The way is through internal critique of thecultural relationship with the environment upon
exposure to otherness.
In a nutshell, the environment is a moral concern
because personal integrity is dependent on therecognition of it as an integral part of a flourishing life
which persons are entitled to have. It is practical as wellbecause social critique elevates the environment to ademand for ethical action in the various spheres ofrecognition or institutions of social freedom. Ethicalaction towards the environment is demonstrated to havegreater normative bite when the institutions are
reoriented to physical well-being and respectful aims.
Deviations from these result to what has been discussed
herein as reification which is the straying away from an
empathetic engagement with the environment.
Capitalism was identified as a socio-economic
misdevelopment which had a far-reaching effect on theenvironment precisely because of the loss of the moral
content immanent in the principle of social cooperationand mutual concern for well-being. This diagnosis is a
showcasing of social critique on which an environmental
ethics, based on a recognitive framework, is set. Fromthe preceding considerations, the visage of anenvironmental ethics from the perspective of a social
philosophy of recognition may then be articulated tohave the following features:(1) The recognition of the fact that personal integrity
and flourishing always includes recognition of man’s
relation with the environment as integral for physicalwell-being. Social recognition in other words includes
respecting different modes of relating with theenvironment that reflect their society from where it
derives its normative legitimacy. Disregard of thisfundamental recognition amounts to disrespect and theemergence social pathologies that manifest inenvironmental predicaments.
(2) The recognition of the ways nature and theenvironment is integrated in the multifaceted dimension ofhuman life—domestic, social, cultural, economic, political,
and religious—the intersubjective frameworks of meaning
on which nature finds articulation in human experience.
An environmental ethics based on social recognition is amultifaceted human concern for praxis in different levels
from which social pathologies could take form. Thus, inorder to identify these pathologies it is imperative tohave the third.
(3) The removal of the barriers of articulation andcommunication. This is important in a two-fold manner:
first, various experiences of disrespect against theenvironment can be articulated free from coercion, andsecond it paves the way for greater democratic
participation and inclusion to decision making processes
in the identification of potential solutions toenvironmental concerns from previously excluded
groups or communities. In this way cultural values
become transparent to itself and to others.
(4) The reflective analysis and internal critique of
cultural values upon exposure to “other” values. This

271

imperative arises out of one culture’s encounter withanother set of norms and values outside of its
epistemological boundaries. This is fruitful likewise in
two ways: while it effects transformation from within it
through the revaluation of the legitimacy of culturalclaims, it prepares itself as well for a more engaged
participation in problem solving and decision making
processes in matters of environmental concerns throughits widening and further enrichment.
(5) The reorientation of the institutions of freedom tothe enhancement of physical well-being of persons and ahealthy environmental identity. To have greater
normativity, ethical action towards the environment
must be incorporated into the different institutions of
freedom—in personal relationships, market economy
and political will-formation. This allows for different
levels of praxis in which the environment could be
reintegrated to the promotion of the well-being of
persons.
Conclusion
The distinctive feature of an environmental ethics drawn
from Honneth’s recognition theory is the joint
identification of the clear place that persons’ relationshipwith nature takes within a moral purview and of the
fields of practical action in which ethical actions towards
the environment could be reoriented. This paper
extended the coverage of personal integrity to include
persons’ relationship with nature and the environment
from the standpoint of physical well-being—that a fullrecognition of persons that contribute to the formationof their individual identity must be congruent to therecognition of their “environmental identity.” The failureor the withholding of this complete recognition reverts
to what Honneth calls as reification—the forgetfulness ofthe fundamental and antecedent recognition thatbehavioural expressions of persons asks from us. It wasalso shown that the simultaneous effect of reification is
the reduction of peoples’ cultural modes of relating withnature to invisibility. Environmental ethics definedwithin the contours of the theory of recognition puts
premium on the task of social critique in order forexperiences of reification to be diagnosed andarticulated, then identify measures for emancipative
action. The identified social pathology in the sphere ofmarket economy that has contributed to a global
reification of peoples’ relationship with the environment,
undermining their well-being is capitalism. Capitalism
has crept into the various spheres of human activity. Its
imperturbable instrumental rationality and indifference
to the environment for the maintenance of cash flow has
caused environmental crises in a global scale. But while
capitalism as a system cannot be radically abolished, arecognition-based ethics shows us the multifacetedmeans for practical action in the same way that
capitalism’s mechanism has infiltrated the different
institutions of social life. The environment as a moralpractical concern demands a re-orientation of ourpersonal relationships, market economy and democratic
political will-formation—the institutions of social
freedom—to one which recognizes the integral place of
caring for the environment in a flourishing life thateveryone deserves.

272
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