Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 27 (3) May 2017www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

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

Contents

page
69

Editorial: Ethical Boundaries- Darryl Macer
Attitudes of Future Doctors of Bangladesh to
Pharmaceutical Incentives and Medical Ethics
70- Tonmoy Biswas & Darryl R.J. Macer
The perception of Muslim motifs and juridical
authorities of the concept of health and its function in
issuing fatwas on abortion81- Saeideh Sayari, DRJ Macer, Siti Nurani binti Nor
The Ethical Dilemma of Human Germline Editing 95-Carol Rizkalla
Circus animals - how much is ‘unfair’?
99-Oana Iftime
ABA Renewal and EJAIB Subscription
103

EJAIB welcome papers! EJAIB charges no fees for
publication and the on-line version has been open
access since 1990
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations(AUSN), Arizona, USA
Email: darryl@eubios.info http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329, Hornby,
Christchurch 8441, New Zealand (Do not post items here;
please use email for all communication)

Editorial: Ethical Boundaries
Setting boundaries is a theme of the papers in thisissue of the journal. In a growing number of countries
circuses are no longer using live animals because of
ethical concerns that the use of live animals harms them,and this theme is explored by Oana Iftime.
Entertainment is a major business, but there aredecreasing opportunities for children to see circuses.
Many circus operators have found that without live
animals fewer people come.
In a related case, SeaWorld in San Diego, California,
has found that in the first year after cancellation of the
Orca (killer whale) show the number of visitors fell by aquarter. Clearly the bioethical choice was not to keep
the orcas in captivity, and to instead encourage people togo whale watching on boats in the ocean (if done
sensitively). Many years ago human freak shows wereattractions, and even Siamese twins were made famous(and could generate an income) by being entertainers.
Exploitation however is an easy boundary to cross, andsetting boundaries and standards lessened theopportunity for blatant exploitation of the vulnerable
that used to occur.
Tonmoy Biswas and Macer explore the attitudes of
medical students in Bangladesh towards what are
acceptable gifts from the representatives ofpharmaceutical companies. This issue is of concern all
around the world, but the results indicate that it is one
which needs to be better discussed in medical ethics
education. There are many avenues for education, butinterestingly the students whose parents were
physicians seemed to be more sensitive to the question,
at least in their attitudes expressed in the survey. The
paper includes an analysis of correlations with gender,
academic year, exposure to pharmaceutical reps, andothers factor in a lot of tables. International comparisons
are made, and further research on this topic will be
useful. It will be particularly interesting to see examples
of correlation of attitude with specific teaching materials
in the curriculum.
Saeideh Sayari et al. call for a broader examination ofreligious ethical principles in Muslim countries that
impose very restrictive regulations on abortion. A
broader concept of health of the mother will be useful for
ethical judgment in many moral dilemmas. Abortion isclearly a contentious issue, but we need to consider thebroader goals of love of life, and the health of the family.
Carol Rizkalla reviews some of the dilemmas ofhuman germ-line editing. As someone who wrote about
these issues in the 1990s, we can see that despite somemoratoriums on germ-line genetic interventions, assome medical interventions such as mitochondrial
donation have become safe, we have to reconsider theboundaries.
One of the concerns of the therapy-enhancement“divide” is boundaries. Should we simply allow law todetermine what is ethical? How much do theseboundaries change over time and place? Should we
legislate and punish violators of some boundary between
the legal and illegal? These are central questions ofbioethics that allow us to move closer to promoting a“good-life” for all moral agents. Education is clearly
critical for students, legislators, and all citizens to
explore the underlying moral values.
- Darryl Macer

70

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

Attitudes of Future Doctors of
Bangladesh to Pharmaceutical
Incentives and Medical Ethics- Tonmoy Biswas, MBBS, MBGPH
Physician, Faridpur Medical College Hospital,
Bangladesh
Email: dr.tsb@yahoo.com-Darryl Macer, PhD, HonD
Director, Eubios Ethics Institute, Japan
Email: Darryl@eubios.info

Abstract
Introduction: Pharmaceutical companies offer
various gifts to physicians to encourage them toprescribe their products. This collaboration has
some negative and positive aspects. Different
countries have established guidelines to limit thecollaboration and reform such relationships. This
study aims to determine the attitude of Bangladeshi
medical students towards pharmaceutical gifts,
physician-pharmacist collaboration, and associatedfactors.
Methods:
An
onlinecross-sectionalandcorrelational study was conducted through email
and Google-Forms among Bangladeshi medical
students. A total of 435 students from different
medical colleges completed the questionnaires in
May and June, 2016.
Results: Monthly parental income was moderate
among the majority of medical students. Less than
16% had a physician or pharmacist parent. Most of
the students (89%) were taught about medical
ethics, but 73% were not taught about the ethics ofphysician-pharmacist collaboration. About 85% did
not have any experience of interaction withmarketing representatives. Drug samples and pennotepads
were
the
most
appreciatedpharmaceutical gifts. Jewelry and gifts costing morethan 100 thousand (Bangladeshi Taka) were said tobe the least appreciated pharmaceutical gifts.
Attitudes
towards
drug
companies
andrepresentatives were assessed by fifteenstatements. Medical students had a variety of
attitudes regarding its
ethical justification.
Attitudes were correlated with gender, parental
income, physician parents, academic years, andhaving been taught about pharmaceuticalcollaboration with physicians.
Conclusion and Recommendations: medical
students should elaborate on ethical reasoning
before accepting pharmaceutical gifts. Medicalcolleges and curriculums should teach them about
the interaction. A national guideline may be needed.

1. Introduction

1.1. Background
It is common practice that pharmaceuticalcompanies offer various gifts and incentives tophysicians to encourage them to prescribe theirdrugs. What are the advantages and risks of thiscollaboration? Are the doctors really influenced?
Does this influence affect prescribing proper drugs
for patients? Can this interaction lead to a biased
decision for therapy? Are these interactions ethicaland lawful? Is receiving incentives ethicallyjustified? When does it fall into the criteria of bribeor kickback? What are the doctors’ views regarding
this issue? Are they aware of the guidelines about
this concern? All these questions are knocking themind of scholars for many years. But the answers
change from time to time, person to person and,place to place as discussed in Biswas and Macer(2017).
There is a complex relation between physicians
and pharmaceutical companies. Pharmaceuticalcompanies offer various gifts, incentives, sponsor
CME (Continuing medical education), and provide
notepads, pens, and samples in many countries
worldwide. The approach somehow can influence
the decision of physicians in the treatment ofpatients which is based on trust driven byphysicians’ autonomy. Many countries like theUnited Sates have restrictions by law uponphysician-pharmaceutical interactions (Cicero etal., 2011, Conn and Vernaglia, 2011). American
Medical Associations’ (AMA) “Ethical Guidelines for
Gifts to Physicians from Industry” in 1998 is an
example of recommendations that is set to maintainthe interaction within ethical limits (Chimonas andRothman, 2005). However, the dilemma in thisfield has remained unsolved (Quan, 2007). The
guidelines are updated year by year to pace withchanging interaction-policies (Austad et al., 2013b).
Canada also set up an ethical guideline in 1991 todeal with this complex phenomenon and topreserve the morality of physicians (Woollard,1991). Japan, Korea, France, and Denmark also haveaddressed this issue with great concern (Rodwin,
2011; Harris, 2009; Kwon, 2003). Some foreign
researchers showed that physicians might have agreat role in drug industries directly (being apharmaceutical physician) and indirectly (Lopes etal., 1993; Hayward, 2011). Physician-pharmacist
collaboration is not an unethical matter always.
There are many positive outcomes if the incentives
are within ethical limits and prescriptions are notbiased. A Canadian study found that physicians andpharmacists both agreed in principle over thecollaboration, but differed in the areas ofcollaboration (Kelly et al., 2013).
Medical students are future doctors. A Saudi
study researched the attitudes of medical students

Eubios Journal of Asian and International Bioethics 27 (May 2017)
towards the incentives from drug companies andfound interesting results (Zaki, 2014). If theattitudes of medical students can be evaluated, we
can determine their level of ethical perception andinvestigate how these issues are being taught tothem. There was no previous study in Bangladesh
in this matter. Therefore, this study aims to answer
these questions from a Bangladeshi standpoint.
What do medical students think about the gifts andincentives? What are their views about theinteraction? Are there any demographic orcorrelated factors that influence the attitudes?
1.2. Rationale
Pharmaceutical representatives offer incentives
to physicians. These kinds of interactions may lead
physicians to irrational prescribing, selection biasof drugs, kickback issues, and other ethicaldilemmas. There is a greater chance that thedoctors may prescribe the drugs of that company
from where they have received some gifts, even if
the drugs are costly and less effective. Thus,
medicinal prices may increase and concerns overthe ethical call for beneficence to patients is mademore difficult. However, positively, representatives
help physicians to learn about new products andprovide needed financial assistance..
1.3. Objective
The general objective was to explore theattitude of future doctors regarding incentives
offered by pharmaceutical companies. Specificobjectives were:− To determine the demographic data, exposure,and experience about pharmaceuticals.
− To determine the attitude of medical students
towards pharmaceutical gifts and incentives.
− To evaluate the attitudes of medical students
towards drug companies and representatives.
− To find out the correlated and associated factorsof attitude by statistical analysis.
− To compare the results with other countries in
the literature.
1.4. Physician-Pharmaceutical Interactions
Physician and pharmaceutical interactions
influence physicians’ behavior and prescribing
patterns (Rubin, 1994). Drug representatives offer
gifts, drug details, and samples to physicians(Cicero et al., 2011; Jain, 2010). Especially financial
assistance and kickbacks raise ethical dilemmas(Rodwin, 2011; Quan, 2007). Some educational
programs, continuing medical education (CME),
and academic events are sponsored by drug
companies in medical schools (Johnson, 2001). In
developed countries, physicians often participate inclinical trials and lectures are facilitated bypharmaceutical companies (Ashar et al., 2004).

71

Meetings between different health professionals
take place there (Huang et al., 2005). Theinteraction is sometimes ethically acceptable andsometimes not (Quan, 2007). Many countries havelaws, legislations, and ethical guidelines regarding
this issue (Gorlach and Pham-Kanter, 2013; Connand Vernaglia, 2011; Harris, 2009). the UnitedStates and Korea have done pharmaceutical reform(Tobbell, 2008; Kwon, 2003). The attitude of
medical students and physicians to the interaction
is different country by country (Kelly et al., 2013;
Austad et al., 2013a). Public perception of thisinteraction varies and is not always positive(Arkinson et al., 2010).

2. Development and implementation of
the Survey
2.1. Ethical Implications
A questionnaire was developed and after pilot
testing it was used. This research was approved by
the American University of Sovereign Nations(AUSN) IRB. The survey was anonymous andconfidential, and gave enough autonomy to theparticipants.
2.2. Independent Demographic Variables
This is a cross-sectional and observational study.
Items include: Gender, current year of study, type of
medical college, parental income, doctor parents,
pharmacist
parents,
known
medicalrepresentatives, being taught about physicianpharmacist
collaboration,interaction
withpharmaceutical companies.
2.3. Dependent Variables
There are many types of gifts, including: Meals,
dry food and snacks, drug samples, pens andnotepads, textbooks, stethoscopes, penlight andmedical equipment, stationary, clothes, gifts(<10,000 BDT), gifts (10,000 to 50,000 BDT), gifts(50,001 to 1,00,000 BDT), gifts (>1,00,000 BDT),
hospital trips, personal or family trips, conference
registration fees, travel fees to any conference,cosmetics, jewelry, computer, and its accessories,
home electronics, home cooking accessories,
unique gadgets, home equipment, game equipment,
festival related gifts, and heard of any other.
2.4. Attitudes towards Pharmaceutical Companies
This was assessed by fifteen statements (A to O):A)theinformation
providedby
drug
representatives about their products can betrusted. B) The information from drug
representatives is important for the physicians. C)
It is ok for the physicians to accept gifts from drug
companies because the drug companies haveminimal influence on them. D) Most seminars

72

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

sponsored by drug companies are helpful andeducational. E) Drug representatives are a usefulway to learn about new drugs. F) Drug company
sponsored seminars are often biased in favor of
their products. G) Gifts from drug companies todoctors lead to increased prices of medicines. H)
Receiving gifts or incentives from pharmaceuticalrepresentatives increases the chance that I will
eventually
recommend/prescribethedrugcompany’s products. I) Drug companies act
unethically in promoting and advertising theirproducts. J) Students should not have any
interaction with drug companies in medical school.
K) Pharmacists should be accountable to thepatients for the drug they provide. L) If a drug
company agreed to pay for the printing costs of all
my class notes in the undergraduate medical
school, I would not mind the logo of that company
appearing in the bottom corner of the first slide ofclass lectures. M) It is acceptable for drug
companies to sponsor events/educational seminars
during medical school. N) Five drugs from fivedifferent companies are identical in terms of price,and therapeutic efficacy. I would preferentiallyprescribe a drug from one of the companies thatprovided me with gifts or incentives. O) There is aneed for guidance regarding the relationshipbetween the pharmaceuticals and the physicians in
the undergraduate medical curriculum.
Two scenario questions were also included.
Attitude towards gifts and incentives were assessedby three levels scale and attitudes towards
pharmaceutical companies were assessed by a fivelevel Likert scale. These variables have been
identified from previous studies by extensive
literature review and an online focus group
discussion. The distribution of the variables isclarified in the questionnaire (Attached inAppendices)
2.5. Study Population and SamplingThis study involved third, fourth, and fifth-year
medical students (as they have exposure in clinicalwards and hospitals) of different medical collegesin Bangladesh. Simple random sampling was done
among the medical students who were invited toparticipate in the study. Those who gave informed
consent were included. Incomplete questionnaires
were excluded. According to sampling statistics, aminimum sample size estimation is 384.16 ≈ 384(n= Z^2 pq/d^2, Z= 1.96, p = 0.5, q= 1-p= 0.5, d=
10% of p= 0.05, in 95% confidence interval). Total
sample size was targeted to be more than 400. At
last 435 clean responses were gathered from thesurvey.
2.6. Validity of Google Questionnaire and Focus
Group Discussion

The Google Questionnaire was created byconsidering the questions used in manyquestionnaires and results of previous studies(Siddiqui et al., 2014) (Sergeant et al., 1996;
McCormick et al., 2001; Gibbons et al., 1998; Yeh etal., 2014). The questionnaire was reviewed byestablished validation criteria and measurement
scales (Van Winkle et al., 2011). Some previous
studies used Google questionnaires on the same
topic had been validated and indexed in PubMed(Zaki, 2014). A Focus Group Discussion (FGD) was
carried out in the social media where a question
was asked to the members of a medical group, both
physicians and students. To include gift-types asmuch as possible, everyone was asked to share
their experience about gifts and incentives from thepharmaceuticals. About two hundred medical
students and physicians answered in the discussion
forum and twenty six types of gifts were finallyadded in the questionnaire for the Likert scale ofappropriateness.
2.7. Procedures and Methods of Data Collection
Respondents were contacted through social
media or personal contacts. The study had taken
double informed consent from the participants. At
first, verbal informed consent was taken before
sending the online link to the consent form. In thelink there was a detailed consent form (available
upon request). The survey needed only 10 to 15
minutes. Once the questionnaire was filled,
respondents were asked to submit. Data obtained
from this survey were totally anonymous. No name
was taken in the questionnaire. After submission,
the responses were unlinked from the respondents
and could never be identified. As this was an online
survey, retrieved responses were archived
automatically in a Google spreadsheet and thenfurther downloaded and saved as Microsoft Excel
file.
2.8. Data Analysis
From Excel, data were converted into SPSS
software for analysis. After interpretation, thepotential correlations among different variables
were analyzed using SPSS software version 21.0.
Pearson Chi-square test was used to find significant
correlations. Two-sided P value less than 0.05 wasconsidered significant in 95% confidence interval.
Statistical Significance is indicated by S=
Significant; NS= Non-Significant. Cross tabulation
was done keeping independent variables in a row(considering 100% in a row) and dependent
variables in a column. Bivariate analysis was doneto assess the relation of attitude with any othervariables.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
3. Results

3.1. Demographics and Experience
There were more female respondents (53%)
than male. Most of the students (59%) werestudying in the fifth year (final year) of MBBS, with
23% in the fourth year and 18% in the third year.
Among the respondents, 45% were from Private
or non-government institutions or medical colleges,
and the rest of them (55%) were from Public orgovernment institutions. Most of the students had
parental income between 20,000 BDT to 50,000
BDT ((80 Bangladeshi Taka = 1 USD).
Only 12% of the respondents had physician
parents and the rest (88%) of them did not haveany parent working as a physician. Similarly, mostof the respondents (96%) did not have any
pharmacist parent while only 4% of them had. 67%of the respondents did not know any medical
representative of any company. But 33% of themknew at least one pharmaceutical representative.
Most of the respondents (89%) claimed thatthey were taught about medical ethics in their
medical college. But most of the students (73%)
said that they were not taught about guidelines ofphysician-pharmacist interaction or collaboration.
While asking ‘where and when were they taught
about physician-pharmacist interaction’, 67
respondents gave specific answers.
Most of the respondents (85%) said that they
did not have any experience of interaction with apharmaceutical company. 57 respondents detailed
about the place and time of the interaction.
3.2. Attitudes towards Gifts and Incentives
The most positively valued gift was drug
samples, where 89% of the respondents agreed(Figure 1). The least valued (only 13%) was Gifts
costing 50 thousand to 100 thousand BDT (80Bangladeshi Taka = 1 USD), because it was notconsideredappropriate.
Specifically”inappropriateness” was perceived most for gifts
costing more than 100 thousand BDT where 75% of
the respondents said so. Only 4% respondents
thought of a pen and notepad as inappropriate gifts.
Attitudes and opinion about different gifts andincentives offered by pharmaceuticals aredescribed in Figure 1 and 2
Respondents were asked whether they heard of
any more types of gifts and incentives or not. A few
respondents reported hearing of Car, Television,
Automobiles, Mobile, Commissions, Flats orApartment, and other Vehicles as gifts bypharmaceutical companies.
3.3. Attitudes towards Drug Company andrepresentatives

73

Attitudes towards drug companies andrepresentatives were determined by 15 statements
and levels of agreement are presented in Table 1.

Opinion on appropriateness of
Gifts-Incentives- Set A
14.5
10.8

Gifts_more than 100K
BDT
Gifts_50K to100K BDT

12.9
17.7

Gifts_10K to 50K BDT

19.1
19.3

69.4

61.6
34.7
18.6
46.7
18.9
20.5
60.7
52.2
23.2
24.6

Gifts_<10K BDT
Clothes
Stationery
MedicalEquipment

15.2
7.1

Stethoscpoe

15.6
10.8

Text Book

14.7
8.3

Pen_Notepad

10.8
3.7

Drug Samples

6.9
4.1

Dry Food_Snacks
Meals
0

Appropriate

74.7

20

Neutral

77.7

73.6
77
85.5
89

46.7
26.7
26.7
38.6
29
32.4
40

60

80

100

Inappropriate

Figure 1: Opinions on Appropriateness ofDifferent Gifts and Incentives (set-A)
Horizontal axis presents percentages of respondents
opinion on gifts and incentives. Abbreviation: K=thousand, BDT= Bangladeshi Taka (80 Bangladeshi
Taka = 1 USD).

4. Two More Attitude Questions andSelf-judged Biasness

A scenario was given to assess the attitude of
future doctors. The scenario was the following: A
drug company wants to increase its visibility to the
medical profession and has recently approached the
medical school. They would like to provide a one-day
seminar regarding their product at the end of thesecond year. In return, they are willing to pay for afraction of the second year tuition for each student
who attends their seminar. As a medical student
faced with increasing tuition costs, I think that it
would be fair if the pharmaceutical company pays
this percentage of my second-year medical school
tuition.

Table 1: Attitudes towards Drug Companies and Representatives (%)
Statements:
Strongly Disagree
disagreeA. The information provided by drug representatives
11.0
28.7
about their products can be trusted
B. The information from drug representatives is
8.5
10.8
important for the physicians
C. It is ok for physicians to accept gifts from drug
21.6
32.2
companies because drug companies have minimal
influence on themD. Most seminars sponsored by drug companies are
6.9
6.0
helpful and educational
E. Drug representatives are a useful way to learn about
8.7
20.7
new drugs
F. Drug company sponsored seminars are often biased
7.9
6.0
in favor of their products
G. Gifts from drug companies to doctors lead to
10.6
18.6
increased prices of medicines
H. Receiving gifts or incentives from pharmaceutical
12.2
22.8
representatives increase the chance that I will
eventually recommend/prescribe the drug
company’s products
I. Drug companies act unethically in promoting and
7.6
12.0
advertising their products
J. Students should not have any interaction with drug
12.6
13.3
companies in medical school
K. Pharmacists should be accountable to the patients
9.4
6.7
for the drug they provide
L. If a drug company agreed to pay for the printing
28.5
15.4
cost of all my class notes in the undergraduate
medical school, I would not mind the logo of thatcompany appearing in the bottom corner of the firstslide of the lecture.
M. It is acceptable for drug companies sponsor
11.0
7.8
events/educational seminars during medical school.
N. Five drugs from five different companies are
33.3
26.2
identical in terms of price, and therapeutic efficacy. I
would preferentially prescribe a drug from one of
the companies that provided me with gifts or
incentives.
O. There is a need for guidance regarding relationship
10.1
5.7
between the pharmaceuticals and the physicians in
the undergraduate medical curriculum
Based on the above scenario, medical students
gave their opinions. Half (54%) declined to accept
any percentage of tuition fees. But 7.4% of themwanted 1 to 10% fees support, 9.9% wanted 10 to
20% fees support, 9% wanted 20 to 30% fees
support, and 19.6% wanted more than 30%
payment of tuition fees by pharmaceuticalcompany.
Another statement examined the attitude of
medical students towards profit and interest of
drug companies. More (62%) of respondents
agreed to a statement that said: “They are primarily
interested in profit: however, they still try to work inthe best interest of doctors and patients”. But 21%
respondents agreed with the statement, “They are

Neutral

Agree

34.3

25.1

Strongly
agree
9

18.6

52.0

10.1

22.5

22.1

1.6

20.2

55.6

11.3

12.9

46.7

11.0

14.5

53.3

19.9

23.2

37.0

10.6

15.2

37.7

12.2

23.7

42.8

14.0

16.3

40.0

17.7

19.8

42.1

22.1

16.8

32.0

7.4

17.0

50.8

13.3

16.8

18.2

5.5

14.9

40.7

28.5

fundamentally interested in profit and never on theside of either doctors or patients”. 17% agreed with,“They are fundamentally on the same side as doctors
and patients and should be regarded as an importantpart of the health care system”.
Respondents were asked whether any previous
experience or interaction biased their responses ornot. Only a few respondents admitted thepossibility of biased responses.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
5. Association and Correlation among
Variables
5.1. Gender and Experience about Pharmaceuticals
Gender had a strong correlation (P value= 0.000,
chi-square) with personally knowing any medical
representative. Only 22% of female respondents
knew any medical representative, compared to
46% of male respondents who knew at least one
medical representative.
Moreover, ‘Gender’ and ‘Experience ofinteraction with pharmaceutical representative’
had also a strong correlation (P value= 0.015, chisquare). Only 10% of female respondents had
experience of interaction with representatives, but
19% of male respondents had experience of thatinteraction.

Game Equipment
Home Equipment
Unique Gadgets
Cooking accessories
Home Electronics
Computer Accessories
Jewelry
Cosmetics
Conference travel fees
Conference registration
Personal/Family_Trip
Hospital Trip0

Appropriate

Neutral

20

40

60

Table 2: Items of Significant Correlation
between Gender (Independent Variable) andOpinion on Gifts and Incentives [Dependent variable
Opinion about Gifts
Meals
Text Books
Stationery options
Clothes
Gifts less than 10,000 BDT
Gifts 50,001 to 100,000 BDT
Gifts more than 100000 BDT
Personal or Family Trip
Computer Accessories
Game Equipment
Festival Gifts

45.7
22.3
32
19.1
21.8
59.1
23.2
20.2
56.6
32.4
24.8
42.8
19.1
17.7
63.2
22.3
18.2
59.5
31.5
19.5
49
14
12.2
73.8
19.3
16.6
64.1
57.2
23.2
19.5
56.3
23.7
20
28
19.8
52.2
60.5
23.2
16.3

Festival Gifts

gender of the respondents as detailed with Pearson
chi-square 2-sided P values in Table 3.

Conference Travel Fees

Opinion on appropriateness of
Gifts-Incentives- Set B

80

Inappropriate

Figure 2: Opinions on Appropriateness ofDifferent Gifts and Incentives (set-B)
Horizontal axis presents percentages of respondents
opinion on gifts and incentives. Abbreviation: K=thousand, BDT= Bangladeshi Taka (80 Bangladeshi
Taka = 1 USD).

5.2. Effect of Gender
Gender was strongly associated with opinions on
12 items (dependent variables) shown as “S” in
Table 2. Thirteen out of fifteen statements ofattitude were associated significantly with the

75

Pearson Chisquare Test: P
value (2-sided)

Statistical
Significan
ce

0.007
0.025
0.016
0.000
0.000
0.019
0.011
0.003
0.023
0.000
0.025
0.000

S
S
S
S
S
S
S
S
S
S
S
S

5.3. Effect of Academic YearA correlation test was run between academic
year and personally knowing any medical
representative. Data showed percentages ofknowing
representatives
increasedwithadvancement of academic year, but there was no
statistically significant correlation (2-sided P value
0.150 in Pearson chi-square test) between those
two variables.
Current academic year of study had a significant
effect on opinion about different gifts andincentives. Academic year was strongly associatedwith opinions on meals, text books, stethoscope,stationary items, clothes, gifts less than 10
thousands, personal or family trip, conference
registration fees, conference travel fees, computer
accessories, unique gadgets, game equipment, andfestival gifts. A significant correlation was foundbetween academic year and 13 dependent variablesof opinions on gifts and incentives (Table 4).
Seven out of fifteen statements of attitude
were associated significantly with academic year of
respondents (Table 5).
5.4. Effects of Parental income
Parental income was strongly associated with
opinions on drug samples, clothes, gifts less than 10
thousand BDT, personal or family trip, computer
accessories, home electronics, cooking accessories,
unique gadgets, and home equipment as describedin Table 6.
Five out of fifteen statements of attitude wereassociated significantly with parental income of
respondents (Table 7).

Eubios Journal of Asian and International Bioethics 27 (May 2017)76

Table 3: Attitudes of Significant Correlation
between Gender (Independent Variable) and
Attitudes toward Drug Companies andRepresentatives
Dependent variable
Attitude towards drug
companiesA.

The information provided bydrug representatives about theirproducts can be trusted
B. The information from drug
representatives is important forthe physicians
C. It is ok for physicians to accept
gifts from drug companies
because drug companies haveminimal influence on them
D. Drug representatives are auseful way to learn about new
drugs
E. Gifts from drug companies todoctors lead to increased prices
of medicines
F. Receiving gifts or incentives
from pharmaceuticalrepresentatives increase thechance that I will eventually
recommend/prescribe the drug
company’s products
G. Drug companies act unethicallyin promoting and advertising
their products
H. Students should not have any
interaction with drug companies
in medical school
I. Pharmacists should be
accountable to the patients forthe drug they provideJ.
If a drug company agreed to pay
for the printing cost of all myclass notes in the undergraduate
medical school, I would notmind the logo of that company
appearing in the bottom cornerof the first slide of the lecture.
K. It is acceptable for drug
companies sponsor
events/educational seminars
during medical school.
L. Five drugs from five different
companies are identical in terms
of price, and therapeutic
efficacy. I would preferentiallyprescribe a drug from one of thecompanies that provided mewith gifts or incentives.
M. There is a need for guidance
regarding relationship between
the pharmaceuticals and thephysicians in the undergraduate
medical curriculum

Pearson Chisquare Test: P
value (2sided)

Statistical
Significan
ce

0.000

S

Table 4: Significant Items of Correlation
between Academic Year (Independent Variable)
and Opinion on Gifts and Incentives.
Dependent variable
Opinion about Gifts
Meals
Text Books
Stethoscope

0.012

S

0.017

S

Stationery options
Clothes
Gifts less than 10,000 BDT
Personal or Family Trip
Conference Registration Fees

0.000

Conference Travel Fees
Computer Accessories

S

Unique Gadgets

0.000

S

0.000

S

0.044

S

0.002

S

0.014

S

0.019

S

Game Equipment
Festival Gifts

Dependent variable

A.
B.
C.

S

S
F.

0.014

0.001
0.016
0.002
0.010
0.030
0.006
0.028
0.002
0.017
0.001
0.012
0.004
0.003

S
S
S
S
S
S
S
S
S
S
S
S
S

Pearson Chisquare Test: P
value (2sided)

Statistical
Signific
ance

Most seminars sponsored bydrug companies are helpful andeducational
Drug representatives are a usefulway to learn about new drugs

0.048

S

0.041

S

Gifts from drug companies todoctors lead to increased prices
of medicines
Receiving gifts or incentives frompharmaceutical representatives
increases the chance that I will
eventually recommend/prescribe
the drug company’s products

0.008

S

0.014

S

Students should not have any
interaction with drug companies
in medical school
Five drugs from five different
companies are identical in terms
of price, and therapeutic efficacy.
I would preferentially prescribe adrug from one of the companies
that provided me with gifts or
incentives.
There is a need for guidance
regarding relationship between
the pharmaceuticals and thephysicians in the undergraduate
medical curriculum

0.015

S

0.016

S

0.004

S

Attitude towards drug companies

E.

0.014

Statistical
Significance

Table 5: Attitudes of Significant Correlation
between Academic Year (Independent Variable)
and Attitude toward Drug Companies andRepresentatives

D.

0.005

Pearson Chisquare Test: P
value (2sided)S
G.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
Table 6: Correlation between Parental Income(Independent Variable) and Opinion on Gifts
and Incentives.
Dependent variable
Opinion about Gifts
Meals
Dry Foods and Snacks
Drug Samples
Pen and Notepad
Text Books
Stethoscope
Medical Equipment
Stationery options
Clothes
Gifts less than 10,000
BDT
Gifts 10001 to 50,000
BDT
Gifts 50,001 to 100,000
BDT
Gifts more than 100000
BDT
Hospital Trip
Personal or Family Trip
Conference Registration
Fees
Conference Travel Fees
Cosmetics
Jewelry
Computer Accessories
Home Electronics
Cooking Accessories
Unique Gadgets
Home Equipment
Game Equipment
Festival Gifts

77

group agreed with appropriateness while 40% of
PP group agreed.
Appropriateness of cosmetics was agreed by
19% of NPP group and 23% of PP group. It wasconsidered inappropriate in the sense of 67% of
NPP group and 46% of PP group. The strongest
correlation was found for the opinion about
computer accessories. Only 11% of PP group found
it appropriate where 34% of NPP group thought so.
Having physician parents and experience about
the pharmaceutical issue were not found to haveany strong correlation (2 sided P value 0.069).

Pearson Chisquare Test: P
value (2-sided)

Statistical
Significanc
e

0.309
0.308
0.028
0.397
0.255
0.430
0.050
0.050
0.021
0.037

NS
NS
S
NS
NS
NS
NS
NS
S
S

0.178

NS

Dependent variable

0.158

NS

Attitude towards drug
companies

0.341

NS

0.081
0.019
0.393

NS
S
NS

0.062
0.052
0.122
0.004
0.043
0.000
0.011
0.001
0.358
0.211

NS
NS
NS
S
S
S
S
S
NS
NS

5.5. Effects of Physician or pharmacist parents
The variable ‘Physician Parents’ is strongly
correlated with the opinions about five gifts thatare meals, hospital trip, conference registration,
cosmetics, and computer accessories (Table 8). As
only 16 respondents had pharmacist parents (only3.7% of total), no correlation statistics was done forthe variable ‘pharmacist parents’. Respondents
having physician parents are named as ‘PP Group’and others having no physician parents are namedas ‘NPP Group’.
Only 25% of PP Group said meals wereappropriate gifts while 31% said they were
inappropriate and 44% were neutral. Comparing tothat, 41% of the NPP Group said a meal was an
appropriate gift, while 33% said it was
inappropriate and 27% were neutral. 44% of PPGroup accepted a hospital trip as appropriate while
63% of NPP group said it was appropriate. In thecase of conference registration fees, 59% of NPPTable 7: Significant Correlations between
Parental Income (Independent Variable) and
Attitude toward Drug Companies andRepresentatives
PearsonChi-square
Test: Pvalue (2sided)

Statistical
SignificanceA.

The information provided bydrug representatives about theirproducts can be trusted

0.017

S

B.

The information from drug
representatives is important forthe physiciansDrug representatives are auseful way to learn about new
drugs
Pharmacists should be
accountable to the patients forthe drug they provide
Five drugs from five different
companies are identical in terms
of price, and therapeutic efficacy.
I would preferentially prescribe
a drug from one of thecompanies that provided mewith gifts or incentives.

0.000

S

0.030

S

0.033

S

0.009

S

C.
D.
E.

Table 8: Items of Significant Correlation
between Physician Parents (Independent
Variable) and Opinion on Different Gifts andIncentives
Dependent
variable
Opinion about
Gifts
Meals
Hospital Trip
Conference
Registration Fees
Cosmetics
ComputerAccessories

Pearson Chi-square
Test: P value (2sided)

Statistical
Significance

0.020
0.034
0.017

S
S
S

0.005
0.000

S
S

Four out of fifteen statements of attitude wereassociated significantly with physician parents of
respondents (Table 9).

Eubios Journal of Asian and International Bioethics 27 (May 2017)78

Table 9: Significant Correlations between
Physician Parents (Independent Variable) and
Attitudes toward Drug Companies andRepresentatives
Dependent variable
Attitude towards drug
companies
A.
B.
C.
D.

Drug representatives are auseful way to learn about new
drugs
Drug company sponsoredseminars are often biased infavor of their products
Gifts from drug companies todoctors lead to increased
prices of medicines
Five drugs from five different
companies are identical interms of price, and therapeutic
efficacy. I would preferentiallyprescribe a drug from one of
the companies that provided
me with gifts or incentives.

Table 10: Correlation between Personally
Knowing a Medical Representative(Independent Variable) and Opinion on Gifts
and Incentives

PearsonChi-square
Test: Pvalue (2sided)

Statistical
Significance

0.011

S

Dry Foods and Snacks
Drug Samples

0.045

S

Pen and Notepad

0.015

S

0.028

Dependent variable
Opinion about Gifts
Meals

S

5.6. Effects of Experience about Pharmaceutical
Companies and Representatives
Correlation between personally knowing a
medical representative were strongly correlatedwith the opinion about seven gifts - text books,
medical equipment, Gifts of 50 thousand to 100
thousand BDT, hospital trip, computer accessories,
cooking accessories, and festival gifts (Table 10).
Respondents who personally know medical
representatives are named as ‘E Group’ and others
who do not know any representative are named as
NE group where E stands for Experience.
About 84% of E group accepted a textbook as
gifts whereas 74% of the NE groups accept that.
And only 5% of E group said it inappropriate
whereas 10% of NE group said so. Acceptance of
medical equipment as gifts was also strongly
correlated with knowing any representatives. With
more respondents of E group (85%) agreeing toaccept it while 74% of NE group said so. The
inappropriateness of medical equipment as gifts
was less in E group (2.8% vs 9.3%).
17% of E group found gifts of 50 thousand BDT
to 100 thousand BDT (80 BDT= 1USD) as
appropriate but only 11% of NE group thought so.
The study found that 67% of E group accepted
appropriateness of hospital trip, but only 57% of
NE group accepted that. Neutrality in case of
hospital trip was less in E group (15% vs 28%)
Computer accessories were appreciated as gifts
by 36% persons of E group, but only 29% of NE
group. More respondents of E group (26%) than NE
group (16%) thought cooking accessories wereappropriate. Festival gifts are more appreciated by
E group than NE (53% vs 42%).

Text Books
Stethoscope
Medical Equipment
Stationery options
Clothes
Gifts less than 10,000
BDT
Gifts 10001 to 50,000
BDT
Gifts 50,001 to 100,000
BDT
Gifts more than 100000
BDT
Hospital Trip
Personal or Family Trip
Conference Registration
Fees
Conference Travel Fees
Cosmetics
Jewelry
Computer Accessories
Home Electronics
Cooking Accessories
Unique Gadgets
Home Equipment
Game Equipment
Festival Gifts

Pearson Chisquare Test:
P value (2sided)

Statistical
Significance

0.989
0.170
0.780
0.166
0.043
0.254
0.018
0.900
0.312
0.096

NS
NS
NS
NS
S
NS
S
NS
NS
NS

0.078

NS

0.004

S

0.394

NS

0.011
0.514
0.691

S
NS
NS

0.513
0.093
0.476
0.010
0.128
0.015
0.574
0.186
0.165
0.028

NS
NS
NS
S
NS
S
NS
NS
NS
S

None of fifteen statements of attitude wereassociated significantly with personally knowing
any representative with Pearson chi-square 2-sided
test.
5.7. Effect of Being Taught about Physicianpharmacist Collaboration
The variable ‘Taught about PhysicianPharmacist Collaboration’ is strongly correlatedwith opinion about computer accessories only.
About 40% of respondents who said that they had
been taught about it said it inappropriate while
52% of other respondents said so. Among the
respondents who was not taught about it, only 27%
accepted it as appropriate, but 41% of the
respondents who had been taught said it was.
Five out of fifteen statements of attitude wereassociated significantly with ‘Taught about
Physician-Pharmacist Collaboration’ (Table 11).

Eubios Journal of Asian and International Bioethics 27 (May 2017)
Table 11: Significant Correlation between Being
Taught about Physician-Pharmacist
Collaboration (Independent Variable) and
Attitudes toward Drug Companies andRepresentatives
Dependent variable
Attitude towards drug
companies
A.
B.

C.
D.
E.

The information from drug
representatives is important
for the physicians
It is ok for physicians to accept
gifts from drug companies
because drug companies haveminimal influence on them
Drug representatives are auseful way to learn about new
drugs
Drug company sponsoredseminars are often biased infavor of their products
Five drugs from five different
companies are identical interms of price, and therapeutic
efficacy. I would preferentiallyprescribe a drug from one of
the companies that provided
me with gifts or incentives.

6. Discussion

PearsonChi-square
Test: Pvalue (2sided)

Statistical
Significance

0.029

S

0.033

S

0.000

S

0.036

S

0.001

S

6.1. Summary of Results
The most common monthly parental income was
between 20,000 to 50,000 BDT for medical
students. Less than 16% medical students had aphysician or pharmacist parent. More than half of
medical students did not know any pharmaceuticalrepresentative personally. Almost all the students(89%) said that they were taught about medical
ethics in medical colleges. But three quarters (73%)
said that they were not taught about ethics ofphysician-pharmacist collaboration.
Most of the medical students (85%) did not haveany experience of interaction with pharmaceuticalcompany representatives though they were inclinical phases of their education (3rd, 4th, and 5thyear). Drug samples and pen-notepads were themost appreciated pharmaceutical gifts, whereas
jewelry and gifts costing more than 100 thousand
BDT (1200 USD) were the least appreciatedpharmaceutical gifts.
Attitude towards drug companies andrepresentatives were explored and the majority ofstudents felt that:• Information provided by drug companies are notalways authentic. But the information isimportant for physicians.
• It is inappropriate to receive pharmaceutical
gifts in spite of the minimal influence ofpharmaceuticals on physicians.

79• Receiving gifts from pharmaceuticals will
eventually affect my prescribing behavior infavor of them.
• Most drug company sponsored seminars are
educational. Although the programs are biased
in favor of company products.
• Drug companies are an important way oflearning new drugs.
• Receiving gifts by physician cause increase of
drug prices.
• Drug companies act unethically in promoting
their products.
• Companies should be accountable to patients forthe drugs provided by them.
• Students should not have any interaction withdrug companies in medical school. But drug
companies
cansponsorseminars
andeducational programs in medical schools.
• If a drug company agrees to pay for the printing
cost of all class notes in the undergraduate
medical school, the logo of that company
appearing in the bottom corner of the first slideof the lecture is acceptable.
• Drug companies should not assist students’
tuition fees.
• They will not choose a drug based on given
incentives or gifts from a bunch of drugs of same
therapeutic efficacy.
• There is a need of guidance about therelationship of pharmaceuticals and physiciansin the undergraduate medical curriculum.
• Pharmaceuticals are primarily interested in
profit. However, they still try to work in the bestinterest of doctors and patients.
The above statements were found to be true basedon attitudes of medical students of Bangladesh.
6.2. Identified Correlations
The sample was enough to represent the
population according to the single proportion
formula of sample size calculation. Based on
statistical significance, distribution of variables, chisquare test, and P values, the following correlations
are proposed in Bangladesh:
Gender of the medical student is associated withexperience about pharmaceutical reps. More male
medical students know medical representative sand have had interactions than female students.
I.
More female students think clothes, gifts
costing more than 50 thousand BDT, gameequipment, and personal and family trip are
inappropriate gifts than do male students. The
study found that the majority of male students
think it appropriate to receive gifts less than 10
thousand BDT, festival gifts, and computer
accessories: whereas the majority of female
students think it inappropriate. More male students

80

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

accept meals, textbooks, and conference travel fees
appropriate than female students. Only stationery
items are accepted by more female students thanmale students.
Change in gender also changes the attitude
towards drug companies and representatives asshown in Table 3. Generally male students weremore supportive of the interactions still the
majority of female students than that of malestudents support the following statements: Drugrepresentatives are a useful way to learn new
drugs; Receiving gifts or incentives frompharmaceuticals increases the chance eventuallyfor me to prescribe that product. The majority ofmales agree but majority of female disagree withthe following statement: “If a drug company agreed
to pay for the printing cost of all my class notes in theundergraduate medical school, I would not mind thelogo of that company appearing in the bottom cornerof the first slide of the lecture”
The academic year of study has no association
with the experience about pharmaceuticals, but has
a strong association with opinions on some specificgifts and incentives. The percentage of students
agreeing to the appropriateness of textbooks,
stethoscope,stationery
items,
conference
registration fees, and conference travel fees isinversely proportional to the academic year. The
more academic year advances, the more thepercentage falls. The proportion of medical
students perceiving inappropriateness of clothes,
meals, personal or family trip, game equipment,
unique gadgets, and computer accessories as gifts is
proportional to the academic year. The moreacademic year advance, the more the proportion
rises.
Third year students could be a better target for
drug companies than later years, but this study did
not explore whether that would have a lasting
influence on attitudes. Festival gifts are accepted tomore third year students than the fourth and fifth
year. Current academic year affects the attitude of
medical students significantly. More third-year
students than other years support the following
statements:
Drugcompanies’
sponsored
educational seminars are helpful; Receiving
pharmaceutical gifts by physicians increase drug
costs; Students should not have interaction withpharmacists in medical schools; I will not choose adrug from a bunch of drugs of same therapeutic
efficacy based on given incentives or gifts.
Morefourth-year students than other years appreciate
drug companies as a useful way to learn about new
drugs.
Parental income has a strong association withthe opinion of medical students on some gifts andincentives, and has a strong correlation with somestatements of attitudes. Comparing to any othergroups, a majority of students having parental
income more than 150 thousand BDT consider thatthe information provided by drug companies areuseful for physicians. More students having
parental income 100 to 150 thousand BDT agree tothe following statements than any other parentalincome groups: Drug representatives are a usefulway to learn about new drugs; Pharmacists shouldbe accountable to the patients for the drug they
provide. The majority of medical students having
monthly-parental-income less than 20 thousand
BDT disagree to choose a drug based on given
incentives or gifts from a bunch of drugs of same
therapeutic efficacy.
Having physician parents has a strong
association with the opinion on some gifts andincentives. Meals, hospital trips, conference
registration fees, and computer accessories areappropriate to more students of non-physician
parents than students of physician parents. It
seems like the students with physician parents
were more sensitive to the influence ofpharmaceutical companies, and that education athome may have been a positive influence on theirethics.
More students who know any medical
representative personally accepts textbooks,
hospital trip, gifts costing 50 to 100 thousand BDT,
computer accessories, cooking accessories, festival
gifts, and medical equipment as appropriate gifts
more than that of those who do not know.
Teaching on physician-pharmacist interaction
does not affect opinion on gifts and incentives
except for computer accessories. Teaching on
physician-pharmacist interaction has an effect on
the attitude of medical students towards drug
companies and representatives. Support for thefollowing statements increases after teaching:
Information of drug companies as important forphysicians; physicians should not accept gifts frompharmaceuticals in spite of minimal influence onthem; I will not choose a drug from a bunch ofdrugs of same therapeutic efficacy based on given
incentives or gifts. Drug companies are accepted asa useful way to learn new drugs to more students
who had not been taught compared to thosestudents who said they had been taught.
6.3. Limitations of the Study
The study findings should be viewed in the
background of certain methodological limitations.
The data collection took place via Google forms
online, so the students who did not have access tothe internet could not participate. Since data werecollected on self-administered questionnaires, we
could not rule out information bias. There is also
some non-response bias. Anonymity andconfidentiality of the respondents were ensured inEubios Journal of Asian and International Bioethics 27 (May 2017)
the study. Hence we did not have the opportunity toidentify and re-invite the non-responders on a
separate occasion. The statements were insufficient
to measure every aspect of attitudes. A longitudinalor cohort study could provide more data.

7. International Comparisons7.1. Comparisons to the United States
Medical students of the United States have moreexperience of interactions with pharmaceuticalindustry than Bangladeshi medical students of this81

study. But less American medical students thanBangladeshi students do not agree that receiving
gifts will affect their prescribing behavior (Austad
et al., 2013b, Sierles et al., 2005). Austad et al.
reported attitude of first and final year students,
Sierles et el. Reported third-year students, and Kim
et al. reported preclinical students (Sierles et al.,2005, Austad et al., 2013b, Kim et al., 2012). Detailsof comparison are presented in Table 12.

Table 12: Comparison of the attitudes of medical students towards pharmaceutical industry in
Bangladesh and the United States (% agreeing to the statement)
Bangladesh (thisstudy)- Final year
students

The United States(Austad et al.)- final
year students (Austad
et al., 2013b)

The United States(Sierles et al.)- Thirdyear students (Sierles
et al., 2005)

The United States (Kimet al.)- Preclinicalstudents (Kim et al.,2012)

Physician Parents
12.8
Personally known
36.6
pharmacists
Experience of interaction with
18.7
pharmaceuticalrepresentatives
Agreement to the following statements:
It is acceptable for physicians to
23.7

24.8
6.7

-

-

44.4

93.2

-

-

-

41.1

52.2

36.3

31.2

-

68.1

36.6

89

-

64.1

-

-

61.5

71.6

76.9

67.4

-

56

30.1

71.3

71

60

69.8

17.3

56.5

33.5

69.1

-

-

accept gifts from pharmaceuticals
Receiving gifts from representatives
increases the
chance that I will eventuallyprescribe the drug company’s
products
Educational programs or rounds bydrug companies are educational andhelpfulDrug companies should sponsor
programs in medical school
Drug company sponsored programs
are often biased in favor of theirproduct
Representative of drug companies
and their materials are useful way tolearn new drugs
Medical students should not haveinteraction with pharmaceuticalrepresentative in medical schools
I was educated about physicianpharmacist interaction

7.2. Comparison to Canada
No Canadian research on medical students
regarding this theme is available. But Sergeant et al.
studied the attitude of the Canadian family
medicine residents towards pharmaceuticalindustry (Sergeant et al., 1996). Details ofcomparison are presented in Table 13.
7.3. Comparison to Germany:
German medical students have moreexperience of interaction with pharmaceuticalindustry than Bangladeshi medical students. But
less German students than Bangladeshi students

agree that receiving gifts will change theirprescribing behavior. And less German students
than Bangladeshi students deny that students
should not have interaction with pharmaceuticals
in medical school (Lieb and Koch, 2013). Details ofcomparison are presented in Table 14.
7.4. Comparison to Pakistan
Siddiqui et al (2014) conducted a similar
study in Pakistani medical students. In
demographics Siddiqui et al. has 31.2%, 44.3%,
24.5% medical students of the third, fourth, andfifth year respectively. But we have 17.9%, 23%,

Eubios Journal of Asian and International Bioethics 27 (May 2017)82

and 59.1% respectively. More Pakistani students
than Bangladeshi students accept drugs companies
to sponsor educational events in medical schools.
But More Bangladeshi students than Pakistani
students consider meals, textbook, pen, stethoscope
as appropriate gifts. Other attitudes sound pretty
similar (Siddiqui et al., 2014). Details of comparison
in presented in Table 15.
Table 13: Comparison of attitudes towards
pharmaceutical industry between medical
students of Bangladesh and Residents ofCanada.
Bangladeshi
Canadian
Agreement to theMedicalFamilyfollowing statements:

The information from drug
representatives is important
for the physicians
Receiving gifts or incentives
from pharmaceuticalrepresentatives increases the
chance that I will eventually
recommend/prescribe thedrug company’s products
There is a need for guidance
regarding relationshipbetween the pharmaceuticals
and the physicians in theundergraduate medical
curriculum
Gifts from drug companies todoctors lead to increased
prices of medicines

Students (thisstudy)

Medicine
Residents(Sergeant etal., 1996)

62.1

58.5

49.9

69.2

47.6

43.4

Experience of pharmaceutical
14.7
interaction
Agreement to the following statements:
Most seminars sponsored by
56.9
drug companies are helpful
and educational
Drug company sponsored
73.2
seminars are often biased infavor of their products
Drug representatives are a
57.7
useful way to learn about new
drugs
Receiving gifts or incentives
49.9
from pharmaceuticalrepresentatives increases the
chance that I will eventually
recommend/prescribe thedrug company’s products
Students should not have any
57.7
interaction with drug
companies in medical school

Physician parents

Bangladeshi
MedicalStudents(this study)

Pakistani
MedicalStudents(Siddiqui etal., 2014)

12

27.1
3

Pharmacist parents
3.7
Agreement to the following statements:
Medical students should not
57.7
have interaction withpharmaceutical representativein medical schools
Physicians should not receive
43.8
gifts in any form
Acceptable gifts: meals, pen,stethoscope, textbook
I will not choose a drug from abunch of drugs of same
therapeutic efficacy based on
given incentives or gifts.
The information provided bydrug representatives about
their products can be trusted

38.6 to
85.5
59.5

35.9

GermanMedicalStudents(Lieb and
Koch,
2013)

87.9
48
89
61
25

22

It is acceptable for drug
companies sponsor
events/educational seminars
during medical school.
If a drug company agreed to
pay for the printing cost of all
my class notes in theundergraduate medical
school, I would not mind thelogo of that company
appearing in the bottom
corner of the first slide of thelecture.
There is a need for guidance
regarding relationshipbetween the pharmaceuticals
and the physicians in theundergraduate medical
curriculum

41.3 to 46

25.4 to29.1
36.3 to40.4
56.1 to56.5

34.1

15.8 to 41.8
(significant
variation
among medicalcolleges)

64.1

79.8 to83.2

39.4

39.1 to49.1

69.2

54.9 to84.2(significant
variation
among
medicalcolleges)

45.6

Table 14: Comparison of the attitude towards
pharmaceutical industry between medical
students of Bangladesh and Germany.
Bangladeshi
MedicalStudents (thisstudy)

Table 15: Comparison of attitudes towards
pharmaceutical industry between medical
students of Bangladesh and Pakistan

7.5. Comparison to Saudi Arabia
No Saudi study on medical students
regarding this theme is available. But the attitude ofSaudi physicians has been studied (Zaki, 2014).
More Saudi physicians than Bangladeshi medical
students find information of drug companies asimportant. But less of them accept that drug
companies are unethically promoting their drugs.
More Saudi physicians than Bangladeshi medical
students disagree that pharmaceutical incentive tophysicians increases drug cost. However, less Saudi
physicians than Bangladeshi medical students
admitted being affected in prescribing behavior byreceiving gifts. Other attitudes are more or less

Eubios Journal of Asian and International Bioethics 27 (May 2017)
similar (Zaki, 2014). Details of comparison inpresented in Table 16.
Table 16: Comparison of attitudes towards
pharmaceutical industry between medical
students of Bangladesh and Physicians of Saudi
Arabia.
Agreement to the following
statements:

Bangladeshi
MedicalStudents (thisstudy)

Saudi
Physicians(Zaki,
2014)

Educated about physicianpharmacist interaction
Personally knowing a drug
representative

27.4

22.8

33.1

28

62.1

80

57.7

65

56.9

45

23.7

20

34.1

42

56.8

31

49.9

34

47.6

27

73.2

63

Agreement to thefollowing statements:
The information from drug
representatives is important
for the physiciansDrug representatives are auseful way to learn about new
drugs
Most seminars sponsored bydrug companies are helpful
and educational
It is ok for physicians to
accept gifts from drug
companies because drug
companies have minimal
influence on them
The information provided bydrug representatives about
their products can be trusted
Drug companies act
unethically in promoting andadvertising their productsReceiving gifts or incentives
from pharmaceuticalrepresentatives increases the
chance that I will eventually
recommend/prescribe thedrug company’s products
Gifts from drug companies todoctors lead to increased
prices of medicines
Drug company sponsoredseminars are often biased infavor of their products

7.6. Further International Comparisons of
Attitudes towards Gifts
Various countries reported attitude of medical
students and physicians towards pharmaceutical
gifts. Some comparisons are presented in Table 17.
7.7. Attitudes towards Pharmaceutical Gifts andAssociated Factors
Among Bangladeshi medical students in thisstudy, drug samples were found to be a more
acceptable gift than other examples. It might be dueto the educational purpose. Drug samples help tolearn about new drugs and formulary. Drugsamples are also appreciated by most students of
Saudi Arabia (Zaki, 2014). But it is not that83

acceptable to German and American medical
students (Lieb and Koch, 2013, Sierles et al., 2005).
Pen and notepads are also highly appreciated by
medical students in this study. Probably it helps
them in academic purpose a lot. About half of Saudi
Arabian physicians support it, though not thatmuch as Bangladeshi students (Zaki, 2014). Jewelry
was most depreciated among the participants inthis study, perhaps because it is a luxury productunrelated to medicine or education.
More than one-third of students in this study
supported meals as gifts. This proportion is lessthan Saudi Arabian physicians and German medical
students (Zaki, 2014, Lieb and Koch, 2013). On theother hand, a very high acceptance of meals as gifts(more than 70%) is seen among the medical
students in Norway and the United States (Lea etal., 2010, Sierles et al., 2005). The probable reason
may be the difference in economic condition andsocial culture.
Among the academic gifts, textbook andstethoscope
werehighlyappreciatedbyBangladeshi medical students in this study. It iseven higher than Saudi physicians, medical
students of Germany, Norway, and the UnitedStates (Zaki, 2014). More than half of this study
participants accepted conference travel fees asappropriate. The ratio is pretty similar to Germany
and Norway (Lieb and Koch, 2013, Lea et al., 2010).
Even more than half of Saudi physicians accept it
too (Zaki, 2014). But less percentage of the U.S.
medical students accept conference travelassistance as appropriate (Sierles et al., 2005).
More than half of Bangladeshi medical students
in this study considered stationary items as
appropriate gifts. But only 36% Saudi physicians
support that (Zaki, 2014). The acceptance rate ofpersonal or family trips as appropriate gifts is 20 to
30% in this study, in Saudi physicians, and the U.S.
medical students. But it is only 11.7% among
German medical students (Zaki, 2014, Sierles et al.,2005, Lieb and Koch, 2013).
We also investigated attitude towards somemore gifts such as dry food, medical equipment,
clothes, gifts in the different amount, hospital trip,
and cosmetics etc. But no significant data isavailable in the literature about them. However,this results also showed a significant correlation
between opinion on some gifts and students’
academic year. This correlation is supported bysome studies of the United States too (Bellin et al.,2004, Fitz et al., 2007). This may be due to thechange in experience and exposure topharmaceutical interaction in different years(Bellin et al., 2004).
This results showed that the more the cost ofgifts increased, the more inappropriate it became to
medical students. Thus, medical students mightTable 17: International Comparison of Attitude of Medical Students and Physicians towards
pharmaceutical gifts (% in Agreement)
Agreement to
Bangladeshi
Saudi
GermanNorwegian
The United
appropriateness of theMedicalPhysicians
Medical
MedicalStates Medical
following gifts:
Students (this(Zaki,
Students
Students (Leastudents
study)
2014)(Lieb andet al., 2010)(Sierles et al.,Koch, 2013)
2005)
Stationery
52.2
36
Textbook
77
55
64.2
69.1 to 84.4
71.1
Stethoscope
73.6
39
56.5
Conference Travel Fees
57.2
63
52.2
47.7 to 82.2
35.4
Conference Registration
56.3
67
Fees
Pen-Notepad
85.5
50
Personal or Family trip
28
26
11.7
30.2
Drug samples
89
66
33.4
21.4
Meals
38.6
28
46.4
75.5 to 90.5
77.4
problem in accepting gifts (Brett et al., 2003,
emphasize on ethical behavior more than selfKorenstein et al., 2010). Even medical students also
beneficence. Female students felt more neutral orappreciate getting gifts or financial support frominappropriate about most of the gifts than male.
pharmaceuticals if they have a financial problem
Probably they were more concern about ethics or it(Grande et al., 2009). And when pharmaceutical
was a part of the female behavioral difference.
companies approach students, their main intention
However, this issue should be investigated further.
is to introduce them repeatedly about the name of
We found that textbook, stethoscope, anddrugs and company. In that way, most of theconference fees were more popular among thetargeted students easily memorize brand names,
junior students than the seniors. It might be due topromotional products, book titles, and company
a fact that juniors were less exposed to those. The
name (Sandberg et al., 1997).
more students expose to them or use them
Although most seminars sponsored by drug
personally, the more acceptability of gifts declines
companies are biased in favor of their products,(Bellin et al., 2004). Clothes, gaming and computer
they are helpful and educational, according to thisequipment and trips are more acceptable to senior
study participants. The academic year of students
students. But the reason behind it is unknown,
affected that attitude of them. Similarly, U.S. study
should be studied.
shows that more than half of the U.S. medical
students believe those programs as educational.
7.8. Attitudes towards Drug Companies and
The attitude of students varies from school to
Associated Factors
school, region to region, and year to year. Variation
The reliability of the information provided byof opinion is also seen between exposed anddrug companies was questioned by almost all
unexposed to pharmaceutical interaction (Grande
students in this study. They might think thatet al., 2009). A systemic review shows that more
information as fabricated for better promotion byclinical students than preclinical students support
drug companies. But despite unreliability, they
those programs as educational (Austad et al., 2011).
thought the information as important of physicians.
About 80% of the U.S. physicians also find theChange in gender and parental income affected
programs helpful (Korenstein et al., 2010). A study
their opinion. Literature also suggests thatamong medical students shows that more than twoinformation provided by them have some potential
third of them agree with the biasness of thebias (Kalb, 2004). Most Canadian residents andprograms (Grande et al., 2009). About two-third ofphysician trainees consider the information as
the U.S. physicians think alike (Korenstein et al.,untrustworthy. Most of them also want to ban this2010). Even nearly half of pharmacy students also
type of pharmaceutical promotion (Hodges, 1995).
think so (Ashker and Burkiewics, 2007). But
Bangladeshi medical students declined thepharmacy students are found to be more taught
appropriateness of accepting pharmaceutical gifts
about drug marketing and professional ethics thanwhether they have minimal influence or not,medical students. They are generally moreaccording to this study. Female gender and formallysupportive to pharmaceutical gifts and sponsoredlearned students about the interaction depreciatedseminars (Monaghan et al., 2003).
the gifts most. In contrast, a systemic review shows
Future doctors of Bangladesh in this study
that more clinical students than preclinical students
considered drug representatives as a useful way tosupport to accept gifts (Austad et al., 2011). And
learn new drugs. Gender, academic year, parental
most physicians do not perceive any ethicalincome, physician parents, and formal education onEubios Journal of Asian and International Bioethics 27 (May 2017)
physician-pharmacist interaction affected theirconsideration. Variation of the agreement was
found in different years. Similarly, a systemic
review shows that more clinical students thanpreclinical students agree to the efficacy ofrepresentatives about educating on new drugs(Austad et al., 2011). About 65% U.S. physiciansalso think this as a way to learn new drugs(Korenstein et al., 2010).
Pharmaceutical gifts to doctors increase
medicinal prices, this students thought so. Gender,
academic year, and physician parents affected thisattitude. However, Bangladesh has no such data ofawareness of physicians about patients’ out-ofpocket expenses. In the United States (U.S.),
physicians are often unconcerned about thatmatter. A study shows that 88% of the U.S.
physicians agree that patients’ drug costs should bewithin their financial ability. But only 59% prefers
less costly drugs to prescribe. While searching forreasons, only 25% of them believe that it is a
responsibility of physicians. And 69% of thembelieve that it is a responsibility of pharmacists(Shrank et al., 2005).
Most of this students agreed that receiving
pharmaceutical
gifts
would
changetheirprescribing behavior in favor of that company. Less
females agreed to that act than males. Academic
year also affected that opinion. Similarly, a systemic
review also supports the variation in different
academic years. It shows that more clinicalstudents than preclinical students are afraid ofbiasness of their future prescribing after receiving
gifts (Austad et al., 2011). A study among the U.S.
medical students shows that from 29.4% to 63.3%
students agree to the influence on prescribing
which may vary from school to school, and year toyear (Grande et al., 2009). Many faculties of medical
schools of the Unite States think that personal
relationship affects prescribing more than receiving
gifts. They ask for more restrictive regulations on it(Banks 3rd and Mainous 3rd, 1992). Most Canadianresidents and interns disagree to have an influenceof gifts on their prescribing behavior. And they
admit having the same behavior and prescription
without any gifts and incentives (Hodges, 1995).
Many physicians of Iraq prefer low-cost gifts thanhigh costs. They also switch to generic prescribing
occasionally (Mikhael and Alhilali, 2014). But
pharmaceutical representatives usually have an
impact on the prescribing behavior of physicians,
claimed by many studies (Cleary, 1992, Korenstein
et al., 2010). Educational assistance, selling andpromoting strategies of pharmaceuticals have asignificant effect on physicians’ prescription(Andaleeb and Tallman, 1995). In the United States,
gifts or quasi-gifts by representatives influence theprescribing pattern of physicians (Berger, 2003).

85

Only detailing by a drug representative can cause
selection bias by a physician (Datta and Dave,2016). So, incentives may easily alter a physician’s
choice of drugs. And if that happens, it will goagainst physicians’ autonomy (Kalb, 2004).
Drug companies act unethically in promoting
and advertising their products, that is what most of
the Bangladeshi medical students thought. Moremale students thought it than female students did.
However, it can be true. Even sometimes
representatives also may feel ethical dilemmas inmarketing products. Especially when they describe
the benefits of their products and offer incentives,
they may sense ethical dilemma but do not express
it (Tengilimoglu et al., 2004). Moreover, it ispossible to change form and content of a drug after
proving its scientific credibility. Sometimes
marketing and promotional strategy become
different in different time and circumstances (vander Hoogte and Pieters, 2010, Bergman et al.,2016).
Students should not have any interaction withdrug companies in medical school, according to theopinions of this study participants. Gender andacademic year affected that attitude. Similarly,
about 33% of the U.S. physicians also suggest thatprohibiting policy (Korenstein et al., 2010). But
some students may desire for this interaction which
varies in different academic years. A systemic
review suggests that preclinical students thanclinical students like to have more interaction withcompanies (Austad et al., 2011).
Most Bangladeshi future doctors think thatpharmacists should be accountable to the patientsfor the drug they provide. Gender and parental
income were associated factor of that opinion. Moremale than female agreed of pharmaceuticalaccountability to patients. However, it is true that if
any drug provided by pharmacists does any harm
to patients, physicians and patients can take lawful
action against that company (Cacciatore, 1997).
Most participants agreed to have the logo of adrug company on the first lecture slide if thecompany agrees to pay for the printing cost of allclass notes in the medical school. Gender affectedthat agreement greatly. More female disagreed but
more male agreed. This study also found that mostmedical students accept drug companies to sponsor
educational events in medical schools. More malethan female significantly supported that matter.
Similarly, a systemic review shows that moreclinical students than preclinical prefer educationalseminars in their medical school (Austad et al.,2011). Moreover, 70% of U.S. physicians also
support that matter (Korenstein et al., 2010). Even
pharmacy students also support those educational
events. A study shows that most of them think the

86

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

events helpful to acquire more knowledge (Ashker
and Burkiewics, 2007).
Future doctors of Bangladesh in this study would
not like to choose a drug from a bunch of drugs ofsame therapeutic efficacy based on given incentives
or gifts. Gender, academic year, parental income,
physician parents, and formal education about theinteraction affected that attitude significantly inthis study. Similarly, a review suggests that morethan half of medical students think that gifts will
not influence their future prescribing behavior. And
more than one-third think that interaction withpharmaceutical will not affect their prescribing
pattern (Carmody and Mansfield, 2010).
There is a need for guidance regarding
physician-pharmaceutical interaction in theundergraduate medical curriculum of Bangladesh,according to the most opinions in this study. As
only a few medical students got a formal education
about it. The scenario of other countries also
supports the fact. A systemic review shows thatmostly less than of half medical students learn
about the ethical interaction in their medical school(Austad et al., 2011). Even in the developed
countries, the knowledge of faculties or resident
doctors about drug marketing, drug cost,
pharmacist collaboration can be limited (Watkins
and Kimberly, 2004). A study shows that only 40%of the physicians of Washington DC agree to have astructured curriculum. More of those curriculums
support the interaction. But most of them want theinteraction to be with institutional affiliation. The
source of drug information and ethics of physicianpharmacist interaction are the most common
subjects among the curriculums (Evans et al.,2016). Education does influence the attitude of
medical students and physicians. So, it is highly
demanded. There will be a positive change inbehavior after learning pros and cons of physicianpharmacist interactions (Vinson et al., 1993)(Hopper et al., 1997).

8. Conclusions and Recommendations

8.1. Conclusions
The interactions between physicians andpharmaceutical producers has continued for
centuries. But sometimes, questions of ethics andconflicts of interests create debates. Pharmaceuticalcompanies offer various gifts to physicians thatvary to be low or high cost, rational or irrational,
and ethical or unethical. Gifts, on one side, help
people to remember the names of new products
and companies. On another side, it may cause
selection bias in physicians’ prescriptions. In
Bangladesh, drug samples, textbooks, stethoscope,pen-notepad, hospital trip, and conference travelregistration fees are highly appreciated among
medical students. The choices are different in somecountries. Meals and festival gifts become moreinappropriate as the academic year advances, may
be due to an increasing professionalism. Parental
income greatly affects the attitudes towards gifts.
Students with low parental income appreciatecomputer accessories and low-cost gifts. The
choices can have a link to their financial problem.
Because, the more parental income grows, the moreinappropriateness of low-cost gifts increases.
Having physician parents also affects the attitude
towards gifts considerably, making them moreneutral. Moreover, personally knowing a
representative affects the choice of gifts too. And it
is surprising that teaching on pharmaceuticals does
not have any association with gift choices. The
reasons should be thoroughly investigated.
The
information
providedby
drug
representatives is not always fully accurate.
Potential biases for drug marketing can be seen
there, Bangladeshi students also do support that.
There is an ethical question in drug marketing
perceivedby
many
medicalstudents,
representatives, and pharmacists. Medical students
consider pharmaceuticals as a way of learning new
drugs. No ethical problem is revealed in learning
new drug names. Accepting gifts are depreciated by
the most Bangladeshi medical students, because of
their ethical concern. They are aware thatpharmaceutical gifts may bias their prescription in
the future. Most of the medical students do notagree to choose a drug from a group of drugs withsame therapeutic efficacy based on company
incentives. And it is an obvious unethical matterthat many physicians in the world write biased
prescriptions in favor of companies who give gifts.
The duty of physicians is to recommend the mostappropriate drug with high efficacy rate at theirknowledge.
Pharmaceuticalincentives
mayincrease the cost of drugs, many medical students
and physicians know that. But they might notconsider it during prescribing. Both pharmacists
and physicians should be concerned about
medicinal prices for greater benefits of patients.
Even pharmacists should be accountable to patientsfor the drugs they provide.
However, pharmaceutical companies often
sponsor educational events in medical schools.
Most of the students and physicians know those arebiased to their products. But they still support theevents considering the educational value andfinancial needs, the support varies among academic
years. Many students also have interaction withpharmaceuticals
inmedicalschools.
The
phenomena are more common in developed
countries than in Bangladesh. But, many students
and physicians of the world want to prohibit thepharmaceutical interaction in medical schools.
However, the attitude of medical students is

Eubios Journal of Asian and International Bioethics 27 (May 2017)
affected by gender, academic year, parental income,
physician parents, and formal education on
pharmaceutical interaction. The attitude may also
vary in different settings, medical schools, andcountries. But it is really astonishing that
personally knowing representatives does not affectthe attitude.
Medical schools do not provide enough teachingon pharmaceutical interaction. Formal education on
medical ethics and ethics of physician-pharmacist
interaction can promote more promising behavior
and ethical medical practice. Formal education also
may help students to set a better attitude.
Collaboration between physicians and pharmacists
is definitely necessary for better health care. But it
is better if the collaboration occurs in a more
ethical way.
8.2 Recommendations
The following recommendations are suggested
according to this study findings:
A. Recommendation for Medical Students:
1. Medical students should learn themselves
about ethical aspects of pharmaceutical gifts.
2. The financial problem should be balanced withthe acceptance of pharmaceutical gifts.
3. Drug
samples,
pen-notepad,
textbook,stethoscope, and other educational equipment canbe acceptable to certain limits. Medical schools candetermine the limits.
4. Students can accept hospital trips, conference
registration-travel fees, and financial assistancefrom pharmaceuticals within a certain limit only
they are in financial crisis and if they disagree towrite biased prescriptions in the future.
5. Medical schools should form guidelines on
pharmaceutical gifts for students with pros andcons listed.
6. They should be introduced by medical schools
to sources of drug information other thanrepresentatives.
7. Students should evaluate the possible positive
and negative aspects of the information provided
by pharmaceuticals.
8. Medical schools should train students on how
can they avoid the influence of pharmaceuticals in
the future practical life.
9. Students should take only the educational partwhen they attend any seminar or event sponsoredby drug companies.
10. Students should interact with more patients inthe clinical wards and know more about theirfinancial problems to buy drugs.
11. Students should evaluate themselves about
positive-negative and ethical-unethical aspects ofthe marketing strategy of drug companies.

87

12. Students should have less interaction withpharmaceuticals in medical schools, they should
not interact before learning ethics.
13. Students should avoid financial assistancefrom drug companies unless they are in extreme
financial crisis. Medical schools can increasefinancial aids to students.
14. Students should learn appropriate prescribingof drugs from a group of drugs of same therapeutic
indication and efficacy.
B. An inclusion of ethics of physicianpharmaceutical interaction should be includedin the undergraduate curriculum. The following
topics should at least be taught:
1. Ethics of physician-pharmaceutical interaction,national and international guidelines
2. Ethics of drug prescribing
3. Physician-patient and pharmacist-patient
relationship
4. Limits and effects of receiving pharmaceuticalgifts
5. History of pharmaceutical reform in different
countries
6. Current policies and scenario in different
countries
7. Marketing strategy of pharmaceuticals
8. Ethics for pharmacists
9. Difference in ethics for medical students andphysicians
10. Effect of prescribing on medicinal prices
C. Recommendation for physicians:
1. Physicians should try to minimize the effect ofdrug representatives while prescribing rationally.
2. Physicians should consider drug prices while
prescribing for poor patients.
3. Physicians should rationally evaluate theinformation provided by drug companies.
4. Physicians ought to be concerned about ethicalmeasures of pharmaceutical marketing.
5. Physicians can move to generic prescribing if
they feel ethical dilemma during practice.
6. If some drugs have same therapeutic efficacy
and equally indicated for a patient, a physician
should choose the cheaper one, not the promoted
one by pharmacists.
7. Physicians should decrease their dependence
on drug industries
8. Physicians should adhere to all statements ofmedical ethics and ethics of pharmaceuticalpractice by all means
D. Recommendationsforpharmaceuticalcompanies:
1. Pharmaceutical companies should promote
their products within the ethical limit.

88

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

2. New drugs with same therapeutic efficacy
should not be marketed for better business.
3. Pharmaceutical companies should makethemselves concerned about medicinal price andpatients’ affordability.
4. Helping people should be prioritized thangaining profits.
5. Pharmaceutical companies should also receive
the idea of ‘do no harm’ for patients.
6. The companies should be accountable topatients for the drugs they supplied
7. Drug companies should have an ethical board
regulating
ethicalmattersofpromotion.
Representatives should report their activities tothat committee
8. Pharmaceuticals should report national ethicalcouncil about their annual marketing and businessfor ethical clearance.
Recommendations for the Government:
The government should establish an ethicalbody to maintain ethics in the health system. The
ethical body can maintain all issues in nationally
includingphysician-pharmacist
collaboration.
Pharmaceuticals should report their annual
activities to that ethical board. A national guidelinein this issue is needed to be structured soon.
Guidelines on ethics of receiving pharmaceutical
gifts and interaction should be more clarified. The
government can train teachers and faculties of
medical schools in this issue so that they can pass it
on to medical students. The national ethical bodycan establish ethical monitoring boards in different
hospitals to maintain different aspects of medical
ethics.

References
AIKIN, K. J., SWASY, J. L. & BRAMAN, A. C. 2004. Patient andphysician attitudes and behaviors associated with DTC
promotion of prescription drugs–summary of FDA survey
research results. Food and Drug Administration. Center for
Drug Evaluation and Research, 19.
ANDALEEB, S. S. & TALLMAN, R. F. 1995. Physician attitudes
toward pharmaceutical sales representatives. Health CareManage Rev, 20, 68-76.
ARKINSON, J., HOLBROOK, A. & WIERCIOCH, W. 2010. Public
perceptions of physician - pharmaceutical industry
interactions: a systematic review. Healthc Policy, 5, 69-89.
ARNEY, J. & LEWIN, B. 2013. Models of physician-patient
relationships
inpharmaceuticaldirect-to-consumer
advertising and consumer interviews. Qual Health Res, 23,937-50.
ASHAR, B. H., MILLER, R. G., GETZ, K. J. & POWE, N. R. 2004.
Prevalence and determinants of physician participation in
conducting pharmaceutical-sponsored clinical trials andlectures. J Gen Intern Med, 19, 1140-5.
ASHKER, S. & BURKIEWICS, J. S. 2007. Pharmacy residents'
attitudes toward pharmaceutical industry promotion.
American Journal of Health-System Pharmacy, 64.
AUSTAD, K. E., AVORN, J., FRANKLIN, J. M. & KESSELHEIM, A. S.
2013a.
Physiciantrainees'interactions
withthepharmaceutical industry. J Gen Intern Med, 28, 1267.

AUSTAD, K. E., AVORN, J., FRANKLIN, J. M., KOWAL, M. K.,
CAMPBELL, E. G. & KESSELHEIM, A. S. 2013b. Changing
interactions between physician trainees and thepharmaceutical industry: a national survey. J Gen Intern Med,28, 1064-71.
AUSTAD, K. E., AVORN, J. & KESSELHEIM, A. S. 2011. Medical
students' exposure to and attitudes about the pharmaceuticalindustry: a systematic review. PLoS Med, 8, e1001037.
AVORN, J. & CHOUDHRY, N. K. 2010. Funding for medical
education: maintaining a healthy separation from industry.
Circulation, 121, 2228-2234.
BANKS 3RD, J. & MAINOUS 3RD, A. 1992. Attitudes of medical
school faculty toward gifts from the pharmaceutical industry.
Academic Medicine, 67, 610-2.
BELLIN, M., MCCARTHY, S., DREVLOW, L. & PIERACH, C. 2004.
Medical students’ exposure to pharmaceutical industry
marketing: a survey at one US medical school. Academic
Medicine, 79, 1041-1045.
BERGER, J. T. 2003. Pharmaceutical industry influences on
physician prescribing: gifts, quasi-gifts, and patient-directed
gifts. Am J Bioeth, 3, 56-7.
BERGMAN, A. A., JAYNES, H. A., GONZALVO, J. D., HUDMON, K. S.,FRANKEL, R. M., KOBYLINSKI, A. L. & ZILLICH, A. J. 2016.
Pharmaceutical Role Expansion and Developments in
Pharmacist-Physician Communication. Health Commun, 31,
161-70.
BERINGS, D., BLONDEEL, L. & HABRAKEN, H. 1994. The effect ofindustry-independent drug information on the prescribing ofbenzodiazepines in general practice. European journal ofclinical pharmacology, 46, 501-505.
BISWAS, T. & MCER, D.R.J. 2017. A review of the interactions
between medical professions and pharmaceutical companies,
Eubios J. Asian & International Bioethics, 27: In Press.
BLAKE, R. L. & EARLY, E. K. 1995. Patients' attitudes about gifts
to physicians from pharmaceutical companies. The Journal of
the American Board of Family Practice, 8, 457-464.
BODENHEIMER, T. 2000. Uneasy alliance. N Engl j Med, 342,
1539-1544.
BRENNAN, T. A., ROTHMAN, D. J., BLANK, L., BLUMENTHAL, D.,
CHIMONAS, S. C., COHEN, J. J., GOLDMAN, J., KASSIRER, J. P.,
KIMBALL, H. & NAUGHTON, J. 2006. Health industry practices
that create conflicts of interest: a policy proposal for academic
medical centers. Jama, 295, 429-433.
BRETT, A. S., BURR, W. & MOLOO, J. 2003. Are gifts frompharmaceutical companies ethically problematic?: a survey ofphysicians. Archives of internal medicine, 163, 2213-2218.
BRODY, H. 2005. The company we keep: why physicians should
refuse to see pharmaceutical representatives. The Annals of
Family Medicine, 3, 82-85.
CACCIATORE, G. G. 1997. Can a physician sue a pharmaceuticalmanufacturer when a drug harms a patient? Tex Med, 93, 624.
CAMPBELL, E. G., WEISSMAN, J. S., EHRINGHAUS, S., RAO, S. R.,
MOY, B., FEIBELMANN, S. & GOOLD, S. D. 2007. Institutional
Academic− Industry Relationships. JAMA, 298, 1779-1786.
CARMODY, D. & MANSFIELD, P. R. 2010. What do medical
students think about pharmaceutical promotion. Aust Med
Stud J, 1, 54-7.
CHIMONAS, S. & ROTHMAN, D. J. 2005. New federal guidelines
for physician-pharmaceutical industry relations: the politics
of policy formation. Health Aff (Millwood), 24, 949-60.
CHREN, M.-M. & LANDEFELD, C. S. 1994. Physicians' behavior
and their interactions with drug companies: a controlled
study of physicians who requested additions to a hospital
drug formulary. Jama, 271, 684-689.
CHREN, M.-M., LANDEFELD, C. S. & MURRAY, T. H. 1989.
Doctors, drug companies, and gifts. Jama, 262, 3448-3451.
CICERO, M. X., CURI, M. B. & MERCURIO, M. 2011. Ethics for thepediatrician: physician interaction with the pharmaceuticalindustry. Pediatr Rev, 32, e1-3.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
CLEARY, J. D. 1992. Impact of pharmaceutical sales
representatives on physician antibiotic prescribing. J Pharm
Technol, 8, 27-9.
CONN, D. K. & STEINGART, A. B. 1997. Diagnosis andmanagement of late life depression: a guide for the primarycare physician. Int J Psychiatry Med, 27, 269-81.
CONN, L. & VERNAGLIA, L. 2011. Shining the light on
physician-pharmaceutical and medical device industry
financial relationships. J Vasc Surg, 54, 22S-5S.
DANZON, P. M. & CHAO, L.-W. 2000. Cross-national pricedifferences for pharmaceuticals: how large, and why? Journalof health economics, 19, 159-195.
DATTA, A. & DAVE, D. 2016. Effects of Physician-directed
Pharmaceutical Promotion on Prescription Behaviors:
Longitudinal Evidence. Health Econ.
DAVIDOFF, F., DEANGELIS, C., DRAZEN, J., NICHOLLS, M., HOEY,
J. & HOJGAARD, L. 2001. COMMENTARY-Sponsorship,
authorship and accountability. Canadian Medical Association
Journal-Journal de l'Association Medicale Canadienne, 165,
786-790.
DESMET, C. 2003. Pharmaceutical firms' generosity andphysicians: legal aspects in Belgium. Med. & L., 22, 473.
DHIMAN, G. J. & AMBER, K. T. 2013. Pharmaceutical ethics andphysician liability in Side Effects. J Med Humanit, 34, 497-503.
EATON, L. 2003. Readers want transparency in link between
doctors and drug firms. BMJ: British Medical Journal, 326,
1352.
EVANS, D. V., WATERS, R. C., OLSEN, C., STEPHENS, M. B. &BROWN, S. R. 2016. Residency Curricula on PhysicianPharmaceutical Industry Interaction: A CERA Study. Fam Med,48, 44-8.
FERGUSON, R. P., RHIM, E., BELIZAIRE, W., EGEDE, L., CARTER,
K. & LANSDALE, T. 1999. Encounters with pharmaceuticalsales representatives among practicing internists. The
American journal of medicine, 107, 149-152.
FITZ, M. M., HOMAN, D., REDDY, S., GRIFFITH III, C. H., BAKER, E.
& SIMPSON, K. P. 2007. The hidden curriculum: medical
students’ changing opinions toward the pharmaceuticalindustry. Academic Medicine, 82, S1-S3.
FROTHINGHAM, R., RELMAN, A. & LEE, T. 2004. Me-Too
Products Friend or Foe? New England Journal of Medicine,350, 2100.
GIBBONS, R. V., LANDRY, F. J., BLOUCH, D. L., JONES, D. L.,
WILLIAMS, F. K., LUCEY, C. R. & KROENKE, K. 1998. A
comparison of physicians’ and patients’ attitudes toward
pharmaceutical industry gifts. Journal of General Internal
Medicine, 13, 151-154.
GLASSMAN, P. A., HUNTER-HAYES, J. & NAKAMURA, T. 1999.
Pharmaceutical
advertising
revenueandphysicianorganizations: how much is too much? West J Med, 171, 234-8.
GORLACH, I. & PHAM-KANTER, G. 2013. Brightening up: theeffect of the Physician Payment Sunshine Act on existing
regulation of pharmaceutical marketing. J Law Med Ethics, 41,
315-22.
GRABOWSKI, H. G. & VERNON, J. M. 1992. Brand loyalty, entry,
and price competition in pharmaceuticals after the 1984 Drug
Act. The Journal of Law & Economics, 35, 331-350.
GRANDE, D., FROSCH, D. L., PERKINS, A. W. & KAHN, B. E. 2009.
Effect of exposure to small pharmaceutical promotional itemson treatment preferences. Archives of Internal Medicine, 169,
887-893.
GREENE, J. A. & PODOLSKY, S. H. 2009. Keeping modern inmedicine: pharmaceutical promotion and physician educationin postwar America. Bull Hist Med, 83, 331-77.
HALL, K. B., TETT, S. E. & NISSEN, L. M. 2006. Perceptions of theinfluence of prescription medicine samples on prescribing byfamily physicians. Medical care, 44, 383-387.
HAMPSON, L. A., AGRAWAL, M., JOFFE, S., GROSS, C. P., VERTER,
J. & EMANUEL, E. J. 2006. Patients' views on financial conflictsof interest in cancer research trials. New England Journal of
Medicine, 355, 2330-2337.

89

HARRIS, G. 2009. Pharmaceutical representatives do influencephysician behaviour. Fam Pract, 26, 169-70.
HAYWARD, C. 2011. So you want to be a pharmaceuticalphysician? Ulster Med J, 80, 176.
HELLERSTEIN, J. K. 1998. The importance of the physician in thegeneric versus trade-name prescription decision. The Rand
journal of economics, 108-136.
HODGES, B. 1995. Interactions with the pharmaceuticalindustry: experiences and attitudes of psychiatry residents,
interns and clerks. CMAJ: Canadian Medical Association
Journal, 153, 553-559.
HOPPER, J. A., SPEECE, M. W. & MUSIAL, J. L. 1997. Effects of an
educational intervention on residents’ knowledge andattitudes
towardinteractions
withpharmaceuticalrepresentatives. Journal of general internal medicine, 12, 639642.
HUANG, F. Y., WEISS, D. S., FENIMORE, P. G., FLEMING, A. M.,
HALLER, E., LICHTMACHER, J. E. & EISENDRATH, S. J. 2005.
The association of pharmaceutical company promotional
spending with resident physician prescribing behavior. Acad
Psychiatry, 29, 500-1.
JAIN, S. 2007. Understanding physician-pharmaceutical industry
interactions: a concise guide, Cambridge University Press.
JAIN, S. 2010. Key aspects of physician and pharmaceuticalindustry relationships for trainees. Acad Psychiatry, 34, 98101.
JOHNS, M. M., BARNES, M. & FLORENCIO, P. S. 2003. Restoringbalance to industry-academia relationships in an era ofinstitutional financial conflicts of interest: promoting research
while maintaining trust. Jama, 289, 741-746.
JOHNSON, R. G. 2001. Physician education and thepharmaceutical industry. Chest, 119, 995-6.
KAHN, N. B. & LICHTER, A. S. 2011. The new CMSS code forinteractions with companies managing relationships tominimize conflicts. Journal of vascular surgery, 54, 34S-40S.
KALB, S. 2004. [Influence of pharmaceutical advertising on thephysician. A contribution to ethics in medicine]. Wurzbg
Medizinhist Mitt, 23, 446-56.
KELLY, D. V., BISHOP, L., YOUNG, S., HAWBOLDT, J., PHILLIPS, L.
& KEOUGH, T. M. 2013. Pharmacist and physician views on
collaborative practice: Findings from the community
pharmaceutical care project. Can Pharm J (Ott), 146, 218-26.
KIM, A., MUMM, L. A. & KORENSTEIN, D. 2012. Routine conflictof interest disclosure by preclinical lecturers and medical
students' attitudes toward the pharmaceutical and device
industries. JAMA, 308, 2187-2189.
KIM, S. Y., MILLARD, R., NISBET, P., COX, C. & CAINE, E. 2004.
Potential research participants’ views regarding researcher
and institutional financial conflicts of interest. Journal of
Medical Ethics, 30, 73-79.
KORENSTEIN, D., KEYHANI, S. & ROSS, J. S. 2010. Physician
attitudes toward industry: a view across the specialties.
Archives of Surgery, 145, 570-577.
KWON, S. 2003. Pharmaceutical reform and physician strikes in
Korea: separation of drug prescribing and dispensing. Soc Sci
Med, 57, 529-38.
LEA, D., SPIGSET, O. & SLØRDAL, L. 2010. Norwegian medical
students’ attitudes towards the pharmaceutical industry.
European journal of clinical pharmacology, 66, 727-733.
LIEB, K. & KOCH, C. 2013. Medical Students’ Attitudes to andContact With the Pharmaceutical Industry. Pharmacology, 1,
100.
LIPSKY, M. S. & TAYLOR, C. A. 1997. The opinions andexperiences of family physicians regarding direct-toconsumer advertising. Journal of Family Practice, 45, 495-500.
LOPES, I. D., GOMES, M. V. & BRANCO, J. C. 1993. [The physician
in the pharmaceutical industry]. Acta Med Port, 6, 361-5.
LURIE, N., RICH, E. C., SIMPSON, D. E., MEYER, J.,
SCHIEDERMAYER, D. L., GOODMAN, J. L. & MCKINNEY, W. P.
1990. Pharmaceutical representatives in academic medical
centers. Journal of General Internal Medicine, 5, 240-243.

90

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

LURK, J. T., DEJONG, D. J., WOODS, T. M., KNELL, M. E. &CARROLL, C. A. 2004. Effects of changes in patient cost sharing
and drug sample policies on prescription drug costs andutilization in a safety-net-provider setting. Am J Health Syst
Pharm, 61, 267-272.
MAINOUS, A. G., 3RD, HUESTON, W. J. & RICH, E. C. 1995. Patient
perceptions of physician acceptance of gifts from thepharmaceutical industry. Arch Fam Med, 4, 335-9.
MIKHAEL, E. M. & ALHILALI, D. N. 2014. Gift acceptance and its
effect on prescribing behavior among Iraqi specialist
physicians. Pharmacology & Pharmacy, 2014.
MIROWSKI, P. & VAN HORN, R. 2005. The contract researchorganization and the commercialization of scientific research.
Social Studies of Science, 35, 503-548.
MIZIK, N. & JACOBSON, R. 2004. Are physicians “easy marks”?
Quantifying the effects of detailing and sampling on newprescriptions. Management Science, 50, 1704-1715.
MOHL, P. C. 2005. Psychiatric training program engagementwith the pharmaceutical industry: an educational issue, notstrictly an ethical one. Academic Psychiatry, 29, 215-221.
MONAGHAN, M. S., GALT, K. A., TURNER, P. D., HOUGHTON, B. L.,
RICH, E. C., MARKERT, R. J. & BERGMAN-EVANS, B. 2003.
Student understanding of the relationship between the healthprofessions and the pharmaceutical industry. Teaching andlearning in medicine, 15, 14-20.
ORLOWSKI, J. P. & WATESKA, L. 1992. The effects ofpharmaceutical firm enticements on physician prescribing
patterns. There's no such thing as a free lunch. Chest, 102,
270-3.
PODOLSKY, S. H. & GREENE, J. A. 2008. A historical perspectiveof pharmaceutical promotion and physician education. JAMA,
300, 831-3.
PUTTAGUNTA, P. S., CAULFIELD, T. A. & GRIENER, G. 2002.
Conflict of interest in clinical research: direct payment to theinvestigators for finding human subjects and healthinformation. Health Law Rev, 10, 30-32.
QUAN, S. F. 2007. Doctor, do you have a minute? The dilemma
posed by physician interaction with the pharmaceuticalindustry. J Clin Sleep Med, 3, 345-6.
RHODES, R. & CAPOZZI, J. D. 2003. The invisible influence ofindustry inducements.
ROBINSON, A. R., HOHMANN, K. B., RIFKIN, J. I., TOPP, D.,
GILROY, C. M., PICKARD, J. A. & ANDERSON, R. J. 2004. Directto-consumer pharmaceutical advertising: physician andpublic opinion and potential effects on the physician-patient
relationship. Arch Intern Med, 164, 427-32.
RODWIN, M. A. 2011. Reforming pharmaceutical industryphysician financial relationships: lessons from the UnitedStates, France, and Japan. J Law Med Ethics, 39, 662-70.
ROSENTHAL, M. B., BERNDT, E. R., DONOHUE, J. M., FRANK, R. G.
& EPSTEIN, A. M. 2002. Promotion of prescription drugs to
consumers. New England Journal of Medicine, 346, 498-505.
RUBIN, P. H. 1994. Pharmaceutical promotion and physician
requests to hospital formularies. JAMA, 272, 355.
SANDBERG, W. S., CARLOS, R., SANDBERG, E. H. & ROIZEN, M. F.
1997. The effect of educational gifts from pharmaceuticalfirms on medical students' recall of company names or
products. Academic Medicine, 72, 916-918.
SEMIN, S., GÜLDAL, D., ÖZÇAKAR, N. & MEVSIM, V. 2006. Whatpatients think about promotional activities of pharmaceuticalcompanies in Turkey. Pharmacy World and Science, 28, 199206.
SERGEANT, M. D., HODGETTS, P. G., GODWIN, M., WALKER, D. M.
& MCHENRY, P. 1996. Interactions with the pharmaceuticalindustry: a survey of family medicine residents in Ontario.
CMAJ: Canadian Medical Association Journal, 155, 1243-1248.
SHRANK, W. H., YOUNG, H. N., ETTNER, S. L., GLASSMAN, P.,
ASCH, S. M. & KRAVITZ, R. L. 2005. Do the incentives in 3-tierpharmaceutical benefit plans operate as intended? Resultsfrom a physician leadership survey. Am J Manag Care, 11, 1622.

SIDDIQUI, U. T., SHAKOOR, A., KIANI, S., ALI, F., SHARIF, M.,
KUMAR, A., RAZA, Q., KHAN, N., ALAMZAIB, S. M. & FARID-ULHUSNAIN, S. 2014. Attitudes of medical students towards
incentives offered by pharmaceutical companies- perspectivefrom a developing nation- a cross sectional study. BMC
Medical Ethics, 15, 36-36.
SIERLES, F. S., BRODKEY, A. C., CLEARY, L. M., MCCURDY, F. A.,
MINTZ, M., FRANK, J., LYNN, D. J., CHAO, J., MORGENSTERN, B.
Z. & SHORE, W. 2005. Medical students’ exposure to andattitudes about drug company interactions: a national survey.
JAMA, 294, 1034-1042.
SMITH, R. 2003. Medical journals and pharmaceuticalcompanies: uneasy bedfellows. British Medical Journal, 326,
1202.
SØNDERGAARD, J., VACH, K., KRAGSTRUP, J. & ANDERSEN, M.
2009. Impact of pharmaceutical representative visits on GPs'
drug preferences. Family practice, 26, 204-209.
SPILKER, B. 2002. The benefits and risks of a pack of M&Ms.
Health Affairs, 21, 243-244.
STEINMAN, M. A., SHLIPAK, M. G. & MCPHEE, S. J. 2001. Of
principles and pens: attitudes and practices of medicine
housestaff toward pharmaceutical industry promotions. The
American journal of medicine, 110, 551-557.
TENGILIMOGLU, D., KISA, A. & EKIYOR, A. 2004. The
pharmaceutical sales rep/physician relationship in Turkey:
ethical issues in an international context. Health Mark Q, 22,
21-39.
TOBBELL, D. A. 2008. Allied against reform: pharmaceuticalindustry-academic physician relations in the United States,
1945-1970. Bull Hist Med, 82, 878-912.
VAN DER HOOGTE, A. R. & PIETERS, T. 2010. [Drug advertising
as communication between the pharmaceutical industry andthe physician: advertisements for psychotropic drugs in the
Dutch medical journal, Nederlands Tijdschrift voor
Geneeskunde, 1900-1940]. Studium (Rotterdam), 3, 139-54.
VINSON, D. C., MCCANDLESS, B. & HOSOKAWA, M. C. 1993.
Medical students' attitudes toward pharmaceutical marketing:possibilities for change. Family medicine, 25, 31-33.
WATKINS, R. S. & KIMBERLY, J., JR. 2004. What residents don't
know about physician-pharmaceutical industry interactions.
Acad Med, 79, 432-7.
WAZANA, A. 2000. Physicians and the pharmaceutical industry:is a gift ever just a gift? Jama, 283, 373-380.
WEINFURT, K. P., FRIEDMAN, J. Y., ALLSBROOK, J. S., DINAN, M.
A., HALL, M. A. & SUGARMAN, J. 2006. Views of potential
research participants on financial conflicts of interest:
barriers and opportunities for effective disclosure. Journal ofgeneral internal medicine, 21, 901-906.
WILSON, F. S. 2003. Continuing medical education: ethicalcollaboration between sponsor and industry. Clinicalorthopaedics and related research, 412, 33-37.
WOFFORD, J. L. & OHL, C. A. 2005. Teaching appropriate
interactions with pharmaceutical company representatives:
the impact of an innovative workshop on student attitudes.
BMC Medical Education, 5, 1.
WOOLLARD, R. F. 1991. Snake oil and Caesar salad: the ethics ofphysician and pharmaceutical relationships. CMAJ, 145, 931-3.
ZAKI, N. M. 2014. Pharmacists’ and physicians’ perception andexposure to drug promotion: A Saudi study. Saudi
Pharmaceutical Journal : SPJ, 22, 528-536.

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

The perception of Muslim motifs
and juridical authorities of theconcept of health and its function
in issuing fatwas on abortion- Saeideh Sayari
University of Malaya, Kuala Lumpur, Malaysia
Email: saeideh_sayari@aol.com- Darryl Macer
American University of Sovereign Nations- Siti Nurani binti Nor
University of Malaya, Kuala Lumpur, Malaysia

Abstract

Muslim jurisprudents and muftis issue fatwas on
abortion based on Ijtihad. Three fundamental
principles of Ijtihad indicate that jurisprudence has
to consider the changes of the time and place, thepublic interest, and the least harm in issuing fatwas.
However, many ignore these principles since they
stick to the traditional concept of health which istheir basis to issue fatwas. In this paper, we analyze
how Islamic jurisprudence, through using theseprinciples in perception of the concept of health,can help to solve the illegal abortion crisis in
Muslim countries.

1. Introduction

Abortion is a global health issue and illegal andunsafe abortions lead to the deaths of an estimated
68,000 women every year. Many of these deaths
occur in countries with a large Muslim population,and in some of these countries the laws are basedon Islamic law. A summary of the legal provisions ispresented later in this paper in Table 1.
Since two main sources of the polices forlegislation about abortion are the political policies
and religious transitions, in Islamic countries which
follow the Islamic law (shari‘a) the guidance on theact of abortion originates from religious decrees
which jurisprudents extract from the sources ofreligion, Qurʾān and tradition.
The jurisprudents extract some decrees basedon dignity of human life and hadith (narrations
from the prophet’s life and decisions) in which theprophet and other religious leaders made decisions
based on the concepts of human life. The key point
here is that these decrees normally originated fromthe jurisprudents’ interpretations of the hadith andalso the main doctrine of the dignity of human life.
These interpretations reflect the historical, cultural,social, political, economic, ethical, and scientificrealities of the era. In other words, thejurisprudents issue the decree based on theirknowledge of their time and concepts which they
have, for example, the concept of human life and91

human health. According to Muslim juridical
attitudes, healthy life is identified as physical healthalthough some of jurisprudents recently also
consider mental health in issuing fatwas. Based on
this approach, juridical authorities issue fatwas on
abortion in the cases in which mother’s life isendangered.
According to the holistic concept of healthdefined by the World Health Organization (WHO),
health includes physical, mental, and social wellbeing and not merely the absence of disease. 1
Therefore, healthy life is considered as acomplicated,
integrated,intertwined,
andmultidimensional net which is related to all aspectsof human life, such as physical, mental, social, andspiritual aspects. The elimination of any aspects ofthis multi-faceted phenomenon may lead to making
harmful decisions on human life.
In this paper, we argue that the reductionist
ideas of some Muslim juridical authorities on theconcept of health follows on the traditional conceptof health according to which the concept of healthwas limited to physical health. We will discuss thatthe adherence to the traditional concept of healthcauses us to ignore the fundamental principles of
ijtihad (making effort to extract the rules form theQurʾān and Sunnah). These principles are:1- Laws change with changes in time and place
2- Choosing the lesser of two harms
3- Preserving public interest2
The importance of discussing the subject is that
not only we can see the effects of the religious ideas
and decrees about the concept of the heath on
reproductive behavior in Muslim countries, eventhose such as Turkey with a secular parliament, butalso they are seen among the Muslim migrants inthe secular countries (Arousell & Carlbom, 2016).

2. Methods
This study is qualitative using published data andanalyses, and academic papers on a variety of
topics about abortion, and uses philosophical andtheological analysis. This research looks at the issue
through the lens of Islamic jurisprudence.

1 Preamble to the Constitution of the World HealthOrganization as adopted by the International HealthConference, New York, 19-22 June, 1946; signed on 22
July 1946 by representatives of 61 States (Official
Records of the World Health Organization, no. 2, p. 100)and entered into force on 7 April 1948.
2 Subhi Mahmassani, Falsafat al- Tashri‘ fi al-Islam, Dar
al-‘Ilm lil-Malayin, Beirut, 1961, pp. 200-207, 408; Azizah
Y. al-Hibri, “Islamic constitutionalism and the concept of
democracy.” Case western reserve journal of Internationallaw. 24, 1 (1992): 3-10.

Eubios Journal of Asian and International Bioethics 27 (May 2017)92
3. The traditional
concept of health

vs.

the

modernThe traditional notion of health was considered as
being in a disease-free state. While this concept issilent about the mental and social aspects, theWorld Health Organization (WHO) refers to three
aspects of health, physical, mental, and social wellbeing. According to Balgo (1978), health is definedas, “a state of body and mind functioning well which
affords man the ability to strive towards his both
functional objectives and culturally desired goals.”
In the past, healthy life was limited to physicallife since human knowledge was limited to simple
rules of the physical body. Although Plato, Aristotle
and other philosophers dealt with the non-physicalpart of the human being as the soul 3 , their
explanations were connected to moral rules.
Therefore, their attitudes refer to the responsibilityof the human being to improve her/his soul.
However, psychology as a scientific field beganaround 200 years ago with Fechner’s critique ofKant’s stricture against quantitative study of mind.4
Then, many schools and fields developed in
psychology. These developments in psychology
clarified the effects of the physical body on themental aspect, and vice versa.
On the other hand, new findings threw light on
the dependence of the social and environmental
factors on the physical and mental part of humanbeings. In fact, human life was considered as asystem in three dimensions, physical, mental, andsocio-environmental. Hence, the healthy life also
depends on the three mentioned parts. As a result,in 1946, WHO declared that health includes
physical, mental, and social well-being and not only
physical health. Therefore, the policy of health inmany countries changed. For example, the UK
government published a document as a policy for
health in 2010. This document states that, “mental
health and well-being are also critical dimensions ofhealth. We know that mental ill health is responsible
for a high proportion of the overall burden of ill
health and prevalence has been rising. We also knowthat mental health and well being are importantfactors for physical health” (Our Health and Well
Being Today, 2010).5 Islamic countries, especiallythe countries mentioned in this research are
member countries of WHO. Therefore, since thedefinitions, rules, and principles of WHO include
the members, Islamic countries are also expected tofollow its rules.
3 Aristotle's
Psychology. Stanford Encyclopedia of
Philosophy.
4 Thomas H. Leahey, A History of Modern Psychology, 3rd
Edition, Pearson, 2001.
5 Our Health and Well Being Today, Department of
Health, Wellington House, 2010, p. 3. www.dh.gov.uk.

In fact, by adding the social and psychologicalaspects, WHO (and thus all member states
officially) acknowledge that the concept of healthand illness are multi-causal, and the focus shiftedfrom a strictly medical perspective in the absenceof illness to evaluation of a person’s status(Boruchovitch & Mednick 2002). Over history wecan see cycles of over-emphasis on law and overemphasis on love as the guidance of religions andpractice, but the abortion laws need to consider
more of the love of life for all moral agents, not justfor the fetus (Macer 1998).

4. The traditional concept of health incontrast to the fundamental principles
of ijtihad
4.1. The first principle: Laws change withchanges in time and place
As mentioned above, in the past, healthy life wasconsidered as life without physical illness.
Therefore, two other aspects of health, mental andsocial well-being were generally not consideredamong the authorities in health and among law
makers.
Muslimjurisprudents
were
notexceptional. In issuing the fatwas, they considered
the traditional concept of health, as they do today.
However, based on the fundamental principle of
ijtihad, laws change with changes in time and place.
In Islam, God has the supreme legislative
power; however, God changed His commands
which He sent to people through prophets. God saidin Qurʾān, “None of Our revelations do We abrogate
or cause to be forgotten, but We substitutesomething better or similar: Knowest thou not that
Allah Hath power over all things?” 6 We can findmany examples on the issue.
Changing the divine rules and command(abrogation) does happen within a religion or
between religions. For example, the Torah allowed
the believers to divorce;7 however, Christ rejected itfor his followers. 8 Another example is about theabrogation of a divine law within Islam; God at firstcommanded to strict punishment for women who
committed adultery; then God changed thepunishment into the milder law. 9 The reason
behind these changes, in general, is that changes
happened in the human cultural, social, historical,
political, individual, and even physiologicalcircumstances.
Therefore, the fundamental principle ofchanging the laws based on the time and place
originate from God Himself. In many cases, the6

2: 106.

7 Book of Deuteronomy, chapter 2.

The New Testament, Gospel Matthew: 19; Gospel Luke:
16.
9 Qurʾān, 4: 15 and 16; 24: 2
8

Eubios Journal of Asian and International Bioethics 27 (May 2017)juridical muftis changed their fatwas. For example,
to have more than one wife for men in Islamic
realm was accepted; however, in some Islamic
countries such as Iran, it has caused many
problems for families, children and women. Finally,some jurisprudents reformed their fatwas; in thiscase, they argue that if a woman considers thisIslamic rule as an insulting law to herself as ahuman being, it should be prohibited in thatsociety.10
4.2. The second principle: Choosing thelesser of two harms
One of the most important reasons for changing thelaws (the first Principle) is to reduce harms inhuman life. For example, before Islam, marriage to
two sisters at the same time for a man was allowed
in some Abrahamic traditions11 but Islam forbade
it12 since it was harmful to the sibling relationship.
The clearest example of this principle is theprohibition of drinking wine in the Qurʾān. “Theyask thee concerning wine and gambling. Say: ‘inthem is great sin, and some profit, for men; but thesin is greater than the profit’.”13 God explained topeople about the advantages and disadvantages ofdrinking wine, however, since its disadvantages are
greater, Muslims were not allowed to drink
although it was not forbidden in previous religions(e.g. Judaism and Christianity).
Therefore, the supreme lawmaker, God, enacts
based on the less harmful side. Some jurisprudents
also followed this principle in social cases; forexample, marriage to non-Muslims often was
forbidden but recently some Islamic scholars or
jurisprudents rejected that and allow all people tomarry to people in other religions.14
4.3. The third principle: Preserving public
interest
The third principle highlights the public interest. In
Islamic jurisprudence, there are many cases inwhich muftis issued or changed the fatwas becauseof public interest. For instance, in 1892, Ayatullah
Shirazi, one of the muftis in Iran, issued a fatwa
according to which using tobacco was forbidden(ḥarām) for Iranian Muslims; then, people broke all
hookahs, so the king was forced to cancel the treaty
with a tobacco company in UK. In another example,
in 1808, Russia attacked Iran and the government
needed to ask people to fight. Then, the king asked

the mofties to issue a fatwa for encouraging people
to fight with enemy. They also allowed thegovernment to take religious payments such as
zakāt to provide the needs of the soldiers.15 Thesejurisprudents issued the fatwa based on a wellknown principle in Islamic tradition; the profit ofMuslim community must be kept, therefore,
everything which is harmful or has disadvantage
for Muslims should be avoided.

5. The concept of health on abortion
according to principles of Ijtihad
The current fatwas on abortion indicate thatabortion is generally forbidden except in serious
conditions in which mother’s life is endangered.
Table 1 shows the abortion laws in various Islamic
countries. The base of these laws are fatwas which
are issued by religious authorities.
The first principle of Ijtihad refers to changes
in terms of time and place. The concepts of time andplace, indicate the social, cultural, economic, andpolitical conditions. Jurisprudents issue fatwas
according to the need of people for a better life.
Also, they issue fatwas in conditions in whichsociety faces a problem. Based on these facts,
abortion is a crisis in most of the Islamic countries,
such as Iran, Indonesia, Bangladesh, and Pakistan.16
To solve the problem, lawmakers need new fatwas
in Islamic countries.
The crisis is not limited to individuals orfamilies, but it affects all the society of a country
and even the global society. The high rate of unsafe
abortions, of unhealthy children, of maternalmortality, and of economic crises clearly
demonstrates a need to revise the rules and fatwas.
According to the second principle of ijtihad, thejuridical circles must issue a fatwa with less harm.
We argue that legal abortion has somedisadvantages such as physical and mental
problems after the abortion; however, illegal
abortions and unwanted children impose a hugecost on society. In legal abortion, mother and family
will get over the physical and mental problems
after a few weeks or a few months, but in the caseof unsafe abortion, it may lead to the death ofmother or serious infections or disabilities. Beside
this, in the case of unwanted children, mother, theunwanted child, the existing children, family, andShykh Jafar Kāshif al-Gheṭā, kashf al-ghiṭā, n.d., Qum,
daftar tablighat islami.
16“New project to help reduce unsafe abortion death rates
in disaster zones “University of Leicester-led research aimed
to implement intervention measures for reproductive healthissues in disaster-prone countries.
http://www2.le.ac.uk/offices/press/pressreleases/2015/november/new-project-to-help-reduce-unsafeabortion-death-rates.
15

10 http://fararu.com/fa/news/10568. 30 April 2008.
11 Such as the marriage of Jacob to Shuaib’s daughters.
12 Qurʾān, 4: 23.
13 Qurʾān, 2: 129.

Ahmad,Ghabel. 2013. jurisprudence, functions andcapabilities . SHariate Aqlani publisher, www. Ghabel.
Net.
14

93

Eubios Journal of Asian and International Bioethics 27 (May 2017)94

Table 1 The number of reasons (1, 2, …) justifying legal abortions in Muslim-majority countries (2011)
1
2
3
4
5
6

7

Afghanistan L

Comoros L.PH

Algeria L.PH.MH

Burkina Faso L.PH.F.I/R

Albania

Bangladesh L

Iran L.F

Chad L.PH.F

Guinea L.PH.F.I/R

Azerbaijan

Brunei L

Jordan L.PH

Gambia L.PH.MH

BahrainDjibouti L

Mali L.I/R

Kuwait L.PH.F

Kazakhstan

Egypt L

Maldives L.PH

Malaysia L.PH.MH

Kyrgyzstan

Guinea-Bissau L

Morocco L.PH

Niger L.PH.F

Tajikistan

Indonesia L

Pakistan L.PH

Qatar L.PH.F

Tunisia

Iraq L

Saudi Arabia L.PH Sierra Leone L.PH.MH

TurkeyLebanon L

Sudan L.R

Turkmenistan

Libya L

Uzbekistan

Mauritania L
Nigeria L
Oman L
Senegal L
Somalia L
Syria L
United Arab Emirates L
Yemen L
18 (38.30%)

9 (19.15%)

8 (17.02%)

2 (4.26%)00

10 (21.28%)

Grounds: L: Abortion allowed to save the life of the woman; PH: Abortion allowed in cases where the pregnancy threatens awoman’s physical health; MH: Abortion allowed in cases where pregnancy threatens the woman’s mental health; F:
Abortion allowed in cases of fetal impairment; I/R: Abortion is allowed in cases of incest or rape; SER: Abortion allowed on
additional enumerated grounds relating to such factors as a woman’s age or capacity to care for a child.
Source: Gilla K Shapiro, “Abortion law in Muslim-majority countries: an overview of the Islamic discourse with policy
implications,” Health policy and planning, 2014: 29, 483-494.

the society will be influenced by physical, mental,
and social health problems.
Finally, regarding the third fundamental
principle of ijtihad, juridical authorities should
consider the public interest which is not limited tojust one society but relates to the whole of humansociety. For example, according to the Center for
Biological Diversity, “A 2009 study of therelationship between population growth and global
warming determined that the “carbon legacy” of justone child can produce 20 times more greenhouse gas
than a person will save by driving a high-mileage car,recycling, using energy-efficient appliances and lightbulbs, etc. Each child born in the United States will
add about 9,441 metric tons of carbon dioxide to thecarbon legacy of an average parent. The study
concludes, “Clearly, the potential savings fromreduced reproduction are huge compared to thesavings that can be achieved by changes inlifestyle.”17
17 “Human population growth and climate change”.

Center for biological diversity.
http://www.biologicaldiversity.org.

According to the United Nations Population
Fund, “human population grew from 1.6 billion to 6.1
billion people during the course of the 20th century.
During that time emissions of CO2, the leading
greenhouse gas, grew 12-fold. And with worldwide
population expected to surpass nine billion over the
next 50 years, environmentalists and others areworried about the ability of the planet to withstandthe added load of greenhouse gases entering theatmosphere and wreaking havoc on ecosystems.”18
6. Conclusion
Ijtihad relies on three fundamental principles whichindicate the flexibility of shari‘a’s laws in terms ofthe changes in the human societies. The concept ofhealth on which jurisprudents issue their fatwaschanged in the new world. In the past, this conceptrefereed to merely the absence of illness. However,
now, this concept includes physical, mental, andsocial well-being. Juridical authorities issue fatwas
about abortion based on the previous concept ofhealth. This fatwas ignore the fundamental
18“Does population growth impact climate change?”
Scientific American. https://www.scientificamerican.com.

Eubios Journal of Asian and International Bioethics 27 (May 2017)
principles of the ijtihad from which these fatwas
originated.

References

Ahmad,Ghabel. 2013.
jurisprudence, functions andcapabilities . SHariate Aqlani publisher, www. Ghabel.
Net.
J, Arousell, A. Carlbom. 2016. “Culture and religious
beliefs in relation to reproductive health.”Best practice& research clinical obstetrics and gynaecology. 32: 7787.
Balog, J. E. (1978). An historical review and philosophicalanalysis of alternative concepts of health and theirrelationship to health education (Unpublisheddissertation). Maryland: University of Maryland, p.
115.
Boruchovitch, E. Mednick, B. R. (2002). “The meaning ofhealth and illness: some considerations for healthpsychology.” Psico-USF. 7 (2): 175-183.
Macer, D.R.J., Bioethics is the Love of Life. Eubios Ethics
Institute, 1998.
Gilla K Shapiro, “Abortion law in Muslim-majority
countries: an overview of the Islamic discourse with
policy implications,” Health policy and planning, 2014:
29, 483-494.

The Ethical Dilemma of Human
Germline Editing-Carol Rizkalla
Royal College of Surgeons in Ireland, Dublin,
Ireland [Postal Address: 104 Panatella Rise NW,
Calgary, Alberta]
Email: rizkalla.carol@gmail.com

1. Introduction

Gene editing provides us with the ability to designand edit genomes of biological entities giving themnew properties. A new technology named the
CRISPR/Cas9 system allows for fast andinexpensive gene editing (1). A piece of RNA, called
guide RNA, contains a set of bases which arecomplementary to the target sequence on the DNA.
The Cas 9 enzyme will follow the guide and will
make a cut across both DNA strands. The affected
cell then recognizes the DNA damage and tries torepair it; this is the point where scientists can use
DNA repair methods to introduce a genetic
mutation (2).
Deliberately manipulating the human germline
for the avoidance of severe inherited diseases has
generally been viewed as acceptable, whereas for‘enhancement’ of human capabilities in some cases
it has been deemed ethical, but in others not. A
disease is any disturbance to the structure orfunction of the body. There are various types of
diseases, ranging from metabolic to inflammatory,
from neoplastic to degenerative, and of course,95

there are also genetic diseases (3). If there was a
way to prevent one of these diseases, should
further exploration be encouraged? Assuming asolution is found, would it be acceptable to use thetechnology for human enhancement? Or are theethical differences too great to overcome?
Should a temporary or permanent global ban
on human germline editing be introduced and, if so,on what basis? Is there an ethical difference
between using gene editing for the avoidance ofsevere inherited diseases or for ‘enhancement’ ofhuman capabilities? Since the genetic changes madein the DNA of gametes and embryos will impact andwill be inherited through the generations, a broad
range of discussions on the prospect of enforcing a
global ban due to the implications of thistechnology has begun (4).

2. Offside effects

Regarding the CRISPR/Cas9 technology, one of theconcerns that have developed is regarding its
accuracy. In theory, it will bind to the target
sequence and no other region. However, whenworking with enzymes that cleave the chains of
nucleotides, such as CRISPR/Cas9, there are offtarget effects towards other locations in the
genome that share similar arrangements with thedestination (5). Since the side effects will be anissue, there have been cultural strategies (6) andchemical molecules (7) that have been reported toincrease the efficiency of genome editing. Further
examination is required to test the possible
detrimental effects on cells or embryos exposed tosuch conditions.
However, in the meantime, bioinformatics hasdeveloped a predictive scoring system that
identifies determinants that influence Cas9
efficiency towards targets, which should improveoutcomes by decreasing the mosaicism rate (whenthe genetic makeup of some cells varies fromothers)(8).

3. Human embryos, a requirement forthe development of research in the field
The concern regarding the inability to predict theconsequences of such a procedure highlights theneed for more data on the safety of suchinterventions, and techniques that could increase
the efficiency (9). The preferred solution todiscarding affected embryos would be using nonviable embryos. These embryos may result from In
Vitro Fertilization, but consent from the donor
couple must first be obtained.

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

Figure 1: “An international regulatory landscape
regarding human germline gene modification. Thirtynine countries were surveyed and categorized as “Banbased on legislation” (25, pink), “Ban based on
guidelines” (4, faint pink), “Ambiguous” (9, gray), and“Restrictive” (1, light gray). Non-colored countries
were excluded in this survey.” (14)Likewise, adult somatic cells give rise tohuman induced pluripotent stem cells, therefore
lessening the ethical concerns. Recent discoveries
have reported that human induced pluripotent
stem cells can differentiate into male germ cellswith the use of bone morphogenetic proteins. Thereis no record of hiPSCs differentiating into humanoocytes, but the scientific community is hopeful inthe data to come from current experiments on mice
(7). Further research must be conducted on theviability of induced germ cells to determine if they
can successfully undergo fertilization and produce
viable embryos.
Therefore, a necessary component in the
preclinical stage assessment may be using embryos
created from human embryonic stem cells as acomparison tool to ensure the reliability ofembryos formed using hiPSC’s. However, to obtainembryonic stem cells, the destruction of theembryo ensues after cell extraction (10). The moral

dilemma here is whether the duty to prevent future
suffering is greater than the obligation to respect
the value of a potential human life. There is a broad
range of views concerning whether or not theembryo has the status of a person; this has createda barrier to further discovery due to current
restrictions in various countries.
4. Varying national laws
Many countries or states have different ethicalpolicies regarding the use or creation of a humanembryo for research. In some countries, where
there is an overabundance in cryopreserved
embryos originally intended for In Vitro
Fertilization, researchers are permitted to utilize
them with informed consent from the donor
parents and by meeting guidelines of institutional
review boards (11). Of the countries that allow
using embryos for research purposes, there is a
restriction to the culture period: 14 days or until
the primitive streak forms (7).
In some countries, using germline genemodification is prohibited until gene correction isenhanced (China, India, Ireland, Japan). The US
National Academy of Sciences and the National
Academy of Medicine have come out with a report(February 2017) outlining several criteria to allow
germline editing clinical trials to continue (12). The

Eubios Journal of Asian and International Bioethics 27 (May 2017)rules include that the benefits must outweigh therisks, a risk of damage to the human embryo willprohibit advancement (13), and the objective ought
to be the prevention of a severely debilitating
disease. In contrast, the UK does not ban the use ofhuman embryos for the sake of reproductive
research as long as the HFEA (regulator in the UK
responsible for overseeing the handling of embryos
and gametes in research and fertility treatments)
approves (14).

5. Making a distinction

The Liang Study used non-viable triponuclear
zygotes with a debilitating disease to investigate
the use of CRISPR/Cas9 gene editing on human cells
to improve data on clinical applications of thistechnology (15). This study underwent a public
outcry; people were calling it the making of‘designer babies’(16).
Some individuals may find it more morally
appropriate to administer genetic interventions in
one case over another. Interventions for genetically
healthy persons are enhancements, whereas in thelatter case they are considered therapy. Some may
say that enhancement expresses dissatisfaction;
conversely, some see it as an opportunity to
improve. However, the concept of improvement is
not morally contentious as we do many activities in
our lives to improve ourselves, some of whichbeing: education, research, and fitness.
Each person is entitled to relief; we see that thedistinction solely focuses on the etiology rather
than the degree of suffering (17). A physician's
professional responsibility to choose the optimaltreatment that promotes quality of life, andrespecting an individual's reproductive autonomy
are valid reasons to move forward with germline
interventions (18).
6. Addressing influential factors
There are two aspects to a disability: the medical
aspect and the social aspect. Society often
categorizes individuals with impairments as
disabled, which prevents them from taking part ineveryday life (19). Disabilities are more often
acquired through an individual’s environment
rather than inherited; meaning that the social
aspect of a disability is a valid concern that ought tobe prioritized to encourage people with disabilities
to live ordinary lives (20). On the other hand,
individuals with medical disabilities, in which theirbody is impaired in some sort due to a genetic
abnormality, can benefit tremendously with thistechnology. The ethical, legal and social frameworkthat will result from the broad adoption of thesetechnologies must be considered. The everoccurring question when addressing humangermline editing for severe inherited diseases is:97

what is seen as a ‘severe’ genetic disease? Ethicaldiscussions must take place as anticipatory
governance; we cannot have a future stall intechnological advancement due to a lack of dialogue
in our current time (21).

Establishing an ethics committee
dedicated to human germline editing
7.

Before considering clinical applications, there
should be a committee in place for each country
that permits the practice of germline modifications.
The research group at the Francis Crick Instituteobtained approval from the HFEA in regards to
conducting experiments involving CRISPR/Cas9
editing of human preimplantation embryos (22).
The UK Health Ministers appoint HFEA
members based on guidelines (the ‘Nolan’
guidelines) that ensure appropriate merit. Also,
members of the HFEA have a broad range ofexpertise to maintain an objective view. Members
range from professions in the field of medicine tothe field of law and from philosophy to religion(22). Further, the fertility clinics and research
centres ought to adhere to the ethical rules andsafety protocols established by the UK government.
Regular inspection of these locations by the HFEA
will ensure compliance. Further, adherence to the
ethical rules and safety protocols set by the UK
government will be enforced by the HFEA throughregular inspection of UK fertility clinics andresearch centres (22).
Knowingthat technicalconcerns
will
eventually be resolved by additional scientificresearch, moral considerations must be the point offocus of public debate (10). Countries should
establish an ethics committee to tackle the ethicaldilemmas according to the ethical rules placed by
thecountry’s
government.
Aftercarefulconsideration of the ethical and social implicationsof such a technology, a country will then be able toestablish policies better suited for their values andbeliefs.
8. Just distribution scheme
The ethics committee dedicated specifically to theediting of human genomes will need to develop
policies that will be the sole source of consolation
when it comes to ethical puzzles to avoid misuse bycertain individuals or organizations.
To address the concern of ‘designer babies,’ weshould discourage inventions that promote
positional advantage and rather posit a justdistribution scheme. Neither race nor sexual
orientations are conditions that require genetic
intervention. If genetic engineering is used to alter
an unborn child’s skin color, sexual orientation orsex, the parents risk advancing discriminatory

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

attitudes. Therefore to ensure just distribution,
genetic interventions ought not to increase
discrimination or racism (23).
Treatment for genetic diseases often requires
intervention at a single particular locus, whereas
phenotypic traits often result from the interaction
between several genes and the environment,
making it difficult to influence these complex traits
through germline modification without a greater
understanding of epigenetics (16). The increased
difficulty may result in only a ‘select few’ being able
to afford the intervention, making genetic
enhancement morally unacceptable as a factor
involved in the ever-increasing gap between therich and the poor. Genetic alterations ought not tobe restricted to a particular sect of society tocoincide with the just distribution scheme.

9. Conclusion

Research towards improving the specificity andreducing the off- target effects of the CRISPR-Cas9
system is developing towards a safe level that will
eventually permit clinical applications in humanpatients. In light of the considerable number ofcountries that are ambiguous, or are awaiting
further developments in the technology (14),establishing a temporary global ban is appropriate.
This temporary global ban will result in the
countries with the ethical policies in place, to laypressure on the countries undecided on the issue athand. Due to the global demand, rather thancontinuing to remain without an opinion, this
temporary ban will provide the incentive forcountries to focus on the ethical, social andevolutionary implications of this biotechnology,
resulting in legislation based on their country’svalues.
Any discovery that seeks to fulfill medicine’s
ethical mandate to help the sick will generatepressure to move from the lab, towards the humanbody (9). Should a country support humangermline editing, they ought to establish a plan of
conduct to prevent abuses of this technology. Whenit comes to administering human germline editing
to those who are considered to have normal bodyfunction and to those of whom are considered
impaired, the distinction is in the etiology.
Conducting this technology with the aid of a justdistribution scheme is recommended to ensure
proper allocation of skills. With ongoingreassessment and public participation preceding
any heritable germline, the ethical concerns thatarise will be acknowledged, and the technology will
be able to move towards clinical trials.

10. References
1. Vassena R, Heindryckx B, Peco R, Pennings G, Raya A,
Sermon K, et al. Genome engineering through

CRISPR/Cas9 technology in the human germline andpluripotent stem cells. Human reproduction update.
2016;22(4):411-9.
2. Ran FA, Hsu PD, Wright J, Agarwala V, Scott DA, Zhang
F. Genome engineering using the CRISPR-Cas9 system.
Nat Protocols. 2013;8(11):2281-308.
3. Crowley L. An Introduction to Human Disease:
Pathology and Pathophysiology Correlations: Jones &Bartlett Learning; 2012.
4. Chan S, Donovan PJ, Douglas T, Gyngell C, Harris J,
Lovell-Badge R, et al. Genome Editing Technologies
and Human Germline Genetic Modification: The
Hinxton Group Consensus Statement. The American
journal of bioethics : AJOB. 2015;15(12):42-7.
5. Miller JC, Tan S, Qiao G, Barlow KA, Wang J, Xia DF, etal. A TALE nuclease architecture for efficient genome
editing. Nature biotechnology. 2011;29(2):143-8.
6. Hatada S, Subramanian A, Mandefro B, Ren S, Kim HW,Tang J, et al. Low-Dose Irradiation Enhances Gene
Targeting in Human Pluripotent Stem Cells. Stem cells
translational medicine. 2015;4(9):998-1010.
7. Yu C, Liu Y, Ma T, Liu K, Xu S, Zhang Y, et al. Small
molecules enhance CRISPR genome editing inpluripotent stem cells. Cell stem cell. 2015;16(2):1427.
8. Moreno-Mateos MA, Vejnar CE, Beaudoin JD,
Fernandez JP, Mis EK, Khokha MK, et al. CRISPRscan:
designing highly efficient sgRNAs for CRISPR-Cas9
targeting in vivo. Nature methods. 2015;12(10):982-8.
9. Sugarman J. Ethics and germline gene editing. EMBO
reports. 2015;16(8):879-80.
10.Denker H-W. Stem Cell Terminology and‘Synthetic'Embryos: A New Debate on Totipotency,
Omnipotency, and Pluripotency and How It Relates toRecent Experimental Data. Cells Tissues Organs.
2014;199(4):221-7.
11.Ishii T, Pera RA, Greely HT. Ethical and legal issues
arising in research on inducing human germ cells frompluripotent stem cells. Cell stem cell. 2013;13(2):1458.
12.Sciences NAo, Medicine NAo, National Academies of
Sciences E, Medicine. Human Genome Editing: Science,
Ethics, and Governance. Washington, DC: The National
Academies Press; 2017. 300 p.
13.Committee on Guidelines for Human Embryonic Stem
Cell Research NRC. Guidelines for Human Embryonic
Stem Cell Research: The National Academies Press;
2005.
14.Araki M, Ishii T. International regulatory landscapeand integration of corrective genome editing into in
vitro fertilization. Reproductive biology andendocrinology. 2014;12(1):108.
15.Liang P, Xu Y, Zhang X, Ding C, Huang R, Zhang Z, et al.
CRISPR/Cas9-mediated gene editing in human
tripronuclear zygotes. Protein & cell. 2015;6(5):36372.
16.Lanphier E, Urnov F. Don't edit the human germ line.
Nature. 2015;519(7544):410.
17.Allhoff F. Germ-line genetic enhancement and
Rawlsian primary goods. Kennedy Institute of Ethics
Journal. 2005;15(1):39-56.
18.Wivel NA, Walters L. Germ-line gene modification anddisease prevention: some medical and ethicalEubios Journal of Asian and International Bioethics 27 (May 2017)perspectives.
SCIENCE-NEW
YORK
THEN
WASHINGTON-. 1993;262:533-.
19.Garland-Thomson R. Disability and social theory: newdevelopments and directions. Taylor & Francis; 2014.
20.Genetics CfR, Committee HG. Position Paper on
Human Germ Line Manipulation. 1992.
21.Wolbring G, Diep L. The Discussions around Precision
Genetic Engineering: Role of and Impact on Disabled
People. Laws. 2016;5(3):37.
22.Fertilisation H, Authority E. HFEA-7th Code ofPractice. 2009.
23.Ishii T. Germ line genome editing in clinics: theapproaches, objectives and global society. Briefings infunctional genomics. 2015:elv053.

Circus animals - how much is‘unfair’?
-Oana Iftime
Faculty of Biology, University
Romania
Email: oiftime@gmail.com

1. IntroductionofBucharest,

In early 2017, eleven out of the thirty-two retired
circus animals that were kept in a facility near
Bucharest, Romania were killed in a fire (Popescu
2017). The public debate moved quickly from theregrettable accidental death of the poor beasts to
the general subject of circus animals. A petition
entitled “We put an end to the exploitation of wild
animals in circuses” (Magor 2017) asking for a banon the use of wild animals in circuses collected
62,096 signatures by February 7th. On January 29,
the General Council of the Bucharest Municipality
released a draft decision to ban animal
performances in the State Circus. Also, the animals
belonging to the State Circus are to be relocated by
an NGO (Klodnischi 2017).
The
use
of
animalsfororganized
entertainment goes back to Antiquity. Ancient
Greek and Roman territories, Egypt, India, Assyria,
Babylon, or China have all known the practice of
keeping wild animals for display and games. In the
Roman Empire, thousands of local and exotic
animals were captured and shipped in poor
conditions to the Capital and other large cities. At
destination, the animals participated in venations(demonstrative hunts taking place in the arena),parades and other types of entertainment. In late
antiquity, Roman arena games had to transform,
due to diminution of resources. Animals in
venations were no longer hunted on the spot but
preserved for return shows. Also, circus-type
performance of tricks by the animals became
encouraged (Mackinnon 2006). In modern Europe,
arena shows were re-discovered by Philip Astley
who started a riding school in 1768, with his

99famousperformancesatAstley'sRoyal
Amphitheatre in London including acrobatic riding(Frost 1881).

2. The underlying reasons
Why do people enjoy animal encounters andperformances? More than a few hypotheses were
formulated on why we cast a special status uponcertain creatures, represented mainly but not
exclusively by pets (Serpell 1996). Beyond theendless speculations on the origin of this behavior
one element stands: in many cultures, someanimals are regarded as special and evenpersonalized and ‘befriended’. People give themnames, include them in their social world, exchange
lots of affection with them and often comment on
their human-like attitudes. In contemporary Europe
pets can get clothes and accessories and be buriedin cemeteries, as humans do. One might also findthis fact interesting that from Aesop’s fables tocontemporary books (animation movies or video
games) the public is attracted by and even accepts
moral criticism from characters represented byanthropomorphic animals (Dunn 2011). Why dopeople exhibit such attitudes remains unclear, with‘humanization’ being identifiable as an aspect
rather than the cause of those peculiar interactions
between humans, and animals. Yet, it is easy toobserve that circus animals are also valued fortraits that are alien to their normal behavior in thewild and rather human-like. Circus is a display of
the unnatural, but this unnatural is attractive as it isrooted in ‘humanization’ of the animals. Circus
animals are clever unusual beasts that are able tolearn and perform. They are trained to react inways that seem ‘human’ in terms of determination,
coordination and performance, which attracts,
amazes and amuses the audience.
Many continue to seek spectacular animal
encounters in spite of the efforts of variousorganizations to educate the public on animal
welfare that might have led to some success interms of concern over the animals in circuses anddisapproval of animal performances (Wells &Hepper 1997; The Scottish Government 2015;
Zanola 2007). During the last years, a stand has aswell been taken by various Western travel brands
and tour operators against exploitation of wild
animals (such as elephants, tigers, and snakes) in
the form of travel attractions such as riding or
various types of performance. Still, the demand foranimal attractions is increasing and new markets
are developing in the world (Baran 2016). Also,
animals continue to be present in some circuses.
Are those speaking against animal circus
performances merely ‘obsessed’ by animal rights?
The July 2013 newsletter of the World Circus

100

Eubios Journal of Asian and International Bioethics 27 (May 2017)Federation (Fédération Mondiale du Cirque 2013)
seems to promote this perspective, whilstcelebrating the legal victory of one renowned circus
company against animal rights organizations andcalling circus fans to organize some sort of acounter-movement in support of maintaining
animal performance in circuses. The Federation
quotes a pro-circus student activist: “... taking thecircus away would be unfair to the public, the circus
performers, and above all, the animals that circuses
strive to take great care of and preserve forgenerations to come”.
As it can be easily observed, the quoted
argument is centered on a term pertaining to ethics
that can inherently bear a highly variable content,
depending on whom do you ask about its
significance: unfair. In this context, one might want
to try and understand what is actually unfair and towhom when it comes about animals in circuses.

3. The unfairness
Violence tends to be generally viewed as unfair. It
has been argued that violence and cruelty once
used in taming and training of circus animals has
gradually been replaced with less brutal methods.
Yet, the training tools and methods that should be
employed for corrective non-violent purposes arestill used by some in a harmful way, so that the
animals get wounded both physically andpsychologically (Humane Review 2012; Kharb
2013; Zoocheck 2016). The case of trainers Rogerand Mary Cawley (a. k. a. Mary Chipperfield), finedfor cruelty to animals became widely known (BBC1999). The undercover footage Elephants in
Circuses: Training and Tragedy (PETA 2007)
revealed to the world certain tamers’ shockingly
brutal perspective. As for the law suit so proudly
mentioned in the World Circus Federation’s
newsletter, a legal analysis published by Beverage(2010) reveals a series of details about how
animals were abused and convincingly argues thatthe ‘victory’ of the entertainment company was
rather technical, due to ‘ambiguities andcounterproductive provisions’ in certain laws andtheir regulatory schemes. Also, circuses have beenrecurrently cited by the United States Departmentof Agriculture for neglect and abuse of animals(Bradshaw 2007).
Furthermore, not only physical violence but
also harming a living being by forcing it beyond its
natural limits tends to be generally considered
unfair; failing to provide proper shelter, food andwater to an individual, be it human or non-humanconstitutes a basic example. Again, how far cantherefore humans push animals so that we decidethat it is unfair? Even circus animals that are notsubject to brutal treatments remain creatures

deprived of a free natural life, convinced to learn
tricks by methods that may be less unpleasant thanthe old-fashioned ones but are still unpleasant, andobliged to observe a strict schedule for our liking
only.
Ecological and behavioral research has
established that there is a deep unavoidable
contradiction between wild animals’ nature andcircus life, as none of the wild species employed incircus performance meets the ‘ideal’ of having low
cognitive function, low ecological and social needs,
such that it would be proper for living in an
artificial environment that bears the characteristics
of a circus (Iossa et al. 2009). As their feeding,social and reproductive behavior are altered andlimited by the specific living conditions, theconclusion that circus animals live an ‘inevitably
impoverished life’ comes natural (Harris et al.
2006). Hand-rearing, training and performance, as
well as frequent travelling affect them (Bekoff et al.
2015). They are exposed to risk factors and develop
various health problems and abnormal behaviors
related to ‘circus life’, with all that such existence
implies (Rose et al. 2006; Animal Defenders
International 2009; Hopster & de Jong 2014;
Machačová et al. 2015; Dorning et al. 2016).
The amount of unfairness has been certainly
considered sufficient by some professional
veterinary organizations so that to express negative
opinions on the welfare of animals in circuses andeventually recommend that the use of wild animals
for performance be banned (e. g. British Veterinary
Association 2012; Federation of Veterinarians ofEurope 2015; Veterinary Ireland 2016).
Worldwide, a number of regions, counties,municipalities, and states have banned totally or
partially the use of animals in circuses. Such bansare in effect in Argentina, Austria, Australia,
Belgium, Bolivia, Brazil, Bosnia and Herzegovina,
Bulgaria, Canada, Chile, Colombia, Costa Rica,
Croatia, Cyprus, Czech Republic, Denmark, Ecuador,
El Salvador, Estonia, Finland, France, Greece,
Hungary, India, Iran, Ireland, Israel, Latvia, Malta,
Mexico, the Netherlands, Norway, Panama,Paraguay, Peru, Poland, Portugal, Republic of
Ireland, Singapore, Slovenia, Spain, Taiwan, UK and
USA (Robinson et al. 2015; Dorning et al. 2016;
Animal Defenders International Circus bans). Steps
are now taken for enacting more bans in the UK(Ares & Cromarty 2016).
Public authorities may ban the use of wild
species in performances, simultaneously advancing
solutions for rehabilitation of the rescued circus
animals. A very good example is represented byIndia, which in 1998 banned the use of lions, tigers,
leopards, bears and monkeys and by 2004 theCentral Zoo Authority reported rehabilitation of
314 lions and tigers from circuses. ConfiscatedEubios Journal of Asian and International Bioethics 27 (May 2017)
animals are sheltered in lifetime-care facilities
established in the off-display area of the zoos
(Gupta & Chakraborty 2005).
Over time, circus has had to adapt and copewith various challenges and changes in the society
and it managed to survive and continue to benumbered among the forms of entertainment
valued by many generations (Loring 2007). The
contemporary world might also accommodate toviewing the animals in circuses not as some sort ofinherited cultural commodity but as valuable living
beings belonging to the realm of nature that we
now so much struggle to learn to respect andprotect, as G. A. Bradshaw (2007) so powerfully put
it “animals are not defined by their circumstances
but affected by them”. Circus can very well exist
and entertain the public without animal
performances. In cirque nouveau, which combines
traditional circus arts with elaborate scenography
into a thematic show of human artistry, sound andlight, the art of entertainment has shown new
performances that keep attracting the public formore than thirty years now.
We have the power to destroy and the power
to build, the power to enslave and the power to set
free, the power to force other living beings to serve
us and the power to force our egoistic wishes tomake room for kindness and compassion. Whatshall we choose, for this world, which is not only
ours but also future generations’?

4. References

Animal Defenders International, Circus bans, available at
http://www.stopcircussuffering.com/circus-bans/;
Ares E., Cromarty H., Wild Animals in Circuses. Briefing
paper Number CBP05992, 29 April 2016, House ofCommons,UK,
availableat
http://researchbriefings.files.parliament.uk/documents/SN05992/SN05992.pdf;
Baran M., Sensitivity to animal exploitation is up. So isdemand for wildlife encounters, Travel weekly, October
31, 2016;
BBC, UK Circus trainers fined for cruelty, BBC News,
Friday,
April
9,
1999,
availableat
http://news.bbc.co.uk/2/hi/uk_news/315146.stm;
Bekoff M., Bruene M., Buyukmihci N. C., Byrne R., deVicente I., Durham D., Ferdowsian H., Gandini G, HarrisS., Hernandez J. M., Inkamba-Nkulu C., KalcherSommersguter E., Mangas Sanchez M., Merskin D.,
Niekisch M., Poole J. H., Preuschoft S., Redmond I., Reiss
D., Schwarzenberger F., Sommer F., Souchal A., Spruijt
B., van Leeuwen E., Visalberghi E., Vonk R., Wrangham
R. (2015) Statement on Ethological Needs and Welfareof Wild Animals, Eurogroup for Animals;
Beverage E. (2010), Abuse Under the Big Top: Seeking
Legal Protection for Circus Elephants after ASPCA v.
Ringling Brothers, Vanderbilt Journal of Entertainment
and Technology Law, Vol. 13, No. 1, pp 155-184.

101

Bradshaw G. A (2007) Elephants in Circuses: Analysis ofPractice, Policy, and Future, Animals and Society
Institute, MI, USA.
Dorning J., Stephen Harris S., Pickett H. (2016), The
welfare of wild animals in travelling circuses, aspecialists’ report prepared for the Welsh Government,
availableat
http://www.ispca.ie/uploads/The_welfare_of_wild_ani
mals_in_travelling_circuses.pdf.
Dunn. E. A. (2011) Talking Animals: A Literature Review
of Anthropomorphism in Children's Books, A Master’s
Paper, University of North Carolina, Chapel Hill, North
Carolina.
Fédération Mondiale du Cirque (2013) Newsletter.
Animal special, No. 3. July 2013, available at
http://www.circusfederation.org/uploads/newsletters/july_2013.pdf
Frost T. (1881) Circus Life and Circus Celebrities, London,
ChattoandWindus,availableat
http://www.circushistory.org/Frost/Frost5.htm;
Gupta B. K., Chakraborty B. (2005) The Role of Zoos in the
Rehabilitation of Animals in the Circus, Journal Of
Applied Animal Welfare Science, 8(4), 285–294;
Harris S., Iossa, G., Soulsbury, C. D. (2006), A review of thewelfare of wild animals in circuses, Royal Society for thePrevention of Cruelty to Animals;
Hopster H., de Jong I.C. (2014) Welfare of sea lions intravelling circuses, Wageningen UR Livestock Research,
Lelystad, The Netherlands, Research Report 770;
Iossa G., Soulsbury C. D., Harris S. (2009) Are wild
animals suited to a travelling circus life? Animal
Welfare, Vol. 18, No. 2, pp. 129-140;
Klodnischi S., Draft decision to ban animal performancesat Bucharest 'Globus' Circus & Variety Company,
AGERPRES, Jan 29, 2017;
Loring P. A. (2007) The Most Resilient Show on Earth: The
Circus as a Model for Viewing Identity, Change, andChaos, Ecology and Society, Vol. 12, No. 1: 9;
Machačová T., Bártová E., Sedlák K., Silvestre P.,
Laricchiuta
P.,
VenezianoV.
(2015)High
Seroprevalence of Toxoplasma gondii in Zoo and Circus
Animals in Italy, Proc Int Conf Dis Zoo Wild Anim 2015,
p. 1-3;
Mackinnon M. (2006) Supplying Exotic Animals for the
Roman Amphitheatre Games: New Reconstructions
Combining Archaeological, Ancient Textual, Historicaland Ethnographic Data, Mouseion, Series III, Vol. 6, No.
2, pp. 137-161;
Magor C. (2017) Punem capat exploatarii animalelorsalbatice in circuri, public petition available athttps://campaniamea.de-clic.ro/petitions/punemcapat-exploatarii-animalelor-salbatice-in-circuri;
PETA (2007) Elephants in Circuses: Training andTragedy,
video
resource
availableathttps://www.youtube.com/watch?v=ZTUol7VrHTg;
Popescu I., 11 animals dead as circus building catches firein Bucharest, Bucharest Insider, Jan 12, 2017;
Rose N., Farinato R., Sherwin (eds.) (2006) The Case
Against Marine Mammals in Captivity, The Humane
Society of the United States and the World Society for
the Protection of Animals;
Serpell J. (1996) In the Company of Animals: A Study of
Human-Animal Relationships, Cambridge University
Press;

102

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

The Scottish Government (2015) Should the use of wild
animals in travelling circuses be banned in Scotland?
Consultation
Analysis,
availableat
http://www.gov.scot/Resource/0048/00480385.pdf;
Veterinary Ireland, Veterinary Organisation’s Opinion on
the Needs of Wild Animals in Travelling Circuses, July
29,
2016,
availableat
http://www.veterinaryireland.ie/images/Veterinary_I
reland_Press_Release_on_Wild_Animals_in_Travelling_
Circuses_29th_July_2016.pdf
Wells D. L., Hepper P. G. (1997) Pet Ownership andAdults' Views on the Use of Animals, Society andAnimals, Vol. 5, No. 1, pp. 45-63;
Zanola R. (2007) Major influences on circus attendance,
Department of Public Policy and Public Choice – POLIS,
Working paper n. 99, October 2007, in "POLIS Working
Papers", Universita’ del Piemonte Orientale “Amedeo
Avogadro” Alessandria, Italy;
Zoocheck (eds.) (2016) Take action for elephants. A
resource guide, Zoocheck, Toronto, Canada;*** (2012) The Circus - A Nightmare For Animals,
Humane Review, Spring/Summer 2012.

For forthcoming conferences see:www.eubios.info or www.ausn.info
Email for information: darryl@eubios.info
Bioethics, Law, and Society: Joint AUSN,
Center for Ethics of Science andTechnology, and Eubios Ethics InstituteConference 24-26 June 2017 at theInternational Peace Park@kaeng Krachan,and Chulalongkorn University, Bangkok,
Thailand. Organizers: Center for Ethics of Scienceand Technology, Chulalongkorn University, Thailand,
American University of Sovereign Nations (AUSN),
USA, the International Peace and Development Ethics
Centre, and Eubios Ethics Institute.

Social Work, Human Security, Ethics andHuman Ability, 1 July 2017, UKM, Kuala
Lumpur, Malaysia. Organizers: UKM; American
University of Sovereign Nations (AUSN), USA, AsiaPacific Forum on Ethics.

Intensive courses on research ethics andbioethics in the Philippines:
Catanduanes State University, Virac, 6July 2017
Bicol University, Legapzi, 7-8 July 2017
University of San Jose-Recoletos, Cebu,
10-12 July
Visions of Social and Ethical Change in
ASEAN, and Beyond, 17 July 2017 (9:0017:00)
Chulalongkorn
University,

Bangkok, Thailand. Organizers: Center for Ethics
of Science and Technology, Chulalongkorn University,
Thailand, American University of Sovereign Nations(AUSN), USA, Youth's UNESCO Club, and Eubios
Ethics Institute.

Joint
AUSN-Bangladesh
SocietyofBioethics Intensive Bioethics Training
Course, 15-16 July 2017 in Dhaka,Bangladesh.
International
Bioethics
Roundtable:
Bioethics Across and Between Continents
and Peoples for the Betterment of All
AUSN, Arizona, USA, 2-5 September 2017
Eighteenth Asian Bioethics Conference:
The Future of Bioethics and Healthcare(ABC18), 25-28
October2017
inSeoul, Republic of Korea, followed by a Joint
AUSN-Gangneung-Wonju
National
University
Intensive
Bioethics
Workshop(ABA Satellite meeting) 29-30
October 2017 in Gangneung, Korea.
The Eleventh Kumamoto University
International
Bioethics
Roundtable: Philosophy and practice of
bioethics across and between cultures,
18-19
November
2017,
University, Japan.
Contact: Kimiko Tashima,ktashima@kumamoto-u.ac.jp

Kumamoto

EJAIB Editor: Darryl Macer
Associate Editor: Nader Ghotbi (Ritsumeikan Asia
Pacific University (APU), Japan)
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico),Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
Alireza Bagheri (Iran), Gerhold Becker (Germany),
Rhyddhi Chakraborty (India/UK), Shamima Lasker(Bangladesh), Minakshi Bhardwaj (UK), Christian Byk(IALES; France), Ken Daniels (New Zealand), Ole Doering(Germany), Amarbayasgalan Dorjderem (Mongolia),
Hasan Erbay (Turkey), Soraj Hongladarom (Thailand),Dena Hsin (Taiwan), Rihito Kimura (Japan), Abby
Lippman (Canada), Umar Jenie (Indonesia), Nobuko
Yasuhara Macer (Japan), Masahiro Morioka (Japan),Anwar Nasim (Pakistan), Jing-Bao Nie (China, New
Zealand), Pinit Ratanakul (Thailand), Qiu Ren Zong
(China), Hyakudai Sakamoto (Japan), Sang-yong Song
(Republic of Korea), Takao Takahashi (Japan), Noritoshi
Tanida (Japan), Ananya Tritipthumrongchok (Thailand),Yanguang Wang (China), Daniel Wikler (USA), Jeong Ro
Yoon (Republic of Korea).

Eubios Journal of Asian and International Bioethics 27 (May 2017)103

Eubios Ethics Institute Publications(Books sent by SAL post, Journal by Airmail - Price included)
Eubios Journal of Asian and International Bioethics (Annual subscription)
Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture
by Darryl Macer, Oct. 1990, 421pp.
Equitable Patent Protection in the Developing World
by William Lesser, May 1991, 150pp.
Attitudes to Genetic Engineering: Japanese and International Comparisons (Bilingual)by Darryl Macer, May 1992 330pp.
Human Genome Research & Society
Eds: Norio Fujiki & Darryl R.J. Macer July 1992
ISBN 0-908897-03-0 (English), 230pp. ISBN 0-908897-04-9 (Japanese), 240pp.
Intractable Neurological Disorders, Human Genome Research and Society Eds: N. Fujiki & D. Macer
Feb. 1994 ISBN 0-908897-06-5 (English), 320pp. ISBN 0-908897-07-3 (Japanese), 340pp.
Bioethics for the People by the People by Darryl Macer, ... May 1994 ISBN 0-908897-05-7, 460pp.
Bioethics in High Schools in Australia, Japan and New Zealand, by D. Macer, Y. Asada,
M. Tsuzuki, S. Akiyama, & N.Y. Macer March 1996, ISBN 0-908897-08-1, 200pp.(A4)
Protection of the Human Genome and Scientific Responsibility (English and Japanese Bilingual)
Editors: Michio Okamoto, Norio Fujiki & D.R.J. Macer, April 1996, ISBN 0-908897-09-X, 210pp.
Bioethics in India Eds: Jayapaul Azariah, Hilda Azariah & Darryl R.J. Macer
June 1998 ISBN 0-908897-10-3, (includes 115 papers) 403 pp. (Printed in India)
Bioethics is Love of Life: An alternative textbook by Darryl Macer, July 1998 ISBN 0-908897-13-8,
152pp. (Note 2nd edition published on iTunes Store as an iBook in 2015)
Bioethics in Asia Eds: Norio Fujiki & Darryl R.J. Macer, (includes 118 papers from Nov.1997
conferences, ABC’97 Kobe and Fukui Satellite) June 1998 ISBN 0-908897-12-X, 478 pp.
October 1999 ISBN 0-908897-14-6 (Japanese), 320pp.
Ethical Challenges as we approach the end of the Human Genome Project
Editor: Darryl Macer, April 2000 ISBN 0-908897-15-4, 124pp.
Bioethics Education in Japanese High Schools (in Japanese only)
Editor: Darryl MacerApril 2000 ISBN 0-908897-16-2, 112pp.
Bioethics and the Impact of Human Genome Research in the 21st Century
Eds: Norio Fujiki, Masakatsu Sudo, & D.R.J. Macer March 2001 (English and Japanese bilingual, 350pp).
Bioethics in Asia in the 21st Century
Eds: Song Sang-yong, Koo Young-Mo & Darryl R.J. Macer
August 2003 ISBN 0-908897-19-7, 450pp.
Challenges for Bioethics from Asia Ed: Darryl R.J. Macer
November 2004 ISBN 0-908897-22-7 656 pp.
A Cross Cultural Introduction to Bioethics, Editor: Darryl Macer 2006, 300pp. (A4)
(Note 2nd edition published on iTunes Store as an iBook in 2015)
Bioethics in Iran, Editor: Alireza Bagheri, 2014. ISBN 978-0-908897-25-4 262 pp.
Bioscience Ethics Education Curriculum for Pre-Schoolers to Elementary Age Children,
Irina Pollard and Amara Zintgraff,. 2017 ISBN 978-0-908897-28-5, 60pp. (A4)
Getting Along: The Wild, Wacky World of Human Relationship, Laura R. Ramnarace 2017
ISBN 978-0-908897-29-2, 73pp. (A4)
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