Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 27 (2) March 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).

Content

page
Editorial: Ethical Therapy - Darryl Macer
37
Obituary to a dear friend, Professor Dr. Jayapaul Azariah- Darryl Macer
38
Obituary to Professor Dr. Jayapaul Azariah
39- Irina Pollard
The world has lost a Bridge between Bioethics and our
Future Prof. Dr. Umar Anggara Jenie - Darryl Macer 39
Risks Present in the Cambodian Surrogacy Business 40-Masayuki Kodama
Consideration of Appropriate Clinical Internships for
Occupational Therapy Students in Japan- K. Yamano 44
Lack of ethical reasoning in the innovation narrative ofOccupational Therapy and Occupational Science
Literature - Samantha Sirianni, and Gregor Wolbring 48
On Being the Hippocratic Doctor: Views of House
officers in a Nigerian Teaching Hospital– O. Okoye, F. Maduka-Okafor, A. Udeaja, A. I Chuku 59
Unethical Clinical Trials in India: A Selective preliminary
overview - Ankita Chakravarty and Ambedkar Bhavan 66
ABA Renewal and EJAIB Subscription (69 online)
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).

Editorial: Ethical Therapy?
Two of the ethical foundations of our life are loving
life, and loving good or beneficence. The articles inthis issue address therapy, trying to make the life ofpeople better than they are because of a disease orcondition. There are two papers on occupational
therapy, which is an applied health science
increasingly being discussed. Yamano looks at what
type of clinical internship can be effective in Japan,
and Sirianni and Wolbring present the results of aliterature analysis. There is little mention of ethics
in that literature to date, yet it clearly raises ethicalissues. Surrogacy discussed by Kodama is incontrast a hot issue of bioethical reflection.
There are two descriptive bioethics papers, one
from Nigeria and one from India, that help fill insome practical circumstances that we need to
pay attention to. Practical ethics is required.
This issue includes obituaries to two leading
figures in Asian Bioethics. I hope that I do notneed to write anymore this year. They bothwere active and supported EJAIB, and Jayapaul
Azariah was a founding associate editor of the
EJAIB – so after three decades he will be sorely
missed.
In this issue I announce theappointment of Prof. Nader Ghotbi as associate
editor who has offered to help, and thank Prof.
Masahiro Morioka who served as associate
editor for 3 decades also. He joins the othermembers of the editorial board. - Darryl Macer
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)

38

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

Obituary to a dear friend,
Professor Dr. Jayapaul Azariah(1939-2017)- Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations

Secretary, Asian Bioethics Association
Director, Eubios Ethics Institute
I am so sad to hear of the passing of my dear friend,colleague, partner in Indian and Asian Bioethics
development, and teacher, Professor Dr. Jayapaul
Azariah.
He is survived by his loving daughters, andfamily, and many dear friends, colleagues andstudents all around the globe.

Jay wrote many papers and books on zoology,
ecology and bioethics. We were inseparable friends
since we met in 1992 in Chennai (Madras as it wascalled in those days), intensely discussing bioethics
and together we worked to develop bioethics in the
1990s. Twenty-five years later the term bioethics is
widely known; many of our students are professors
themselves developing a global understanding of
bioethics. Bioethics is widely known in India andother countries in Asia, thanks to him.
Jay also served on the Board of Directors of theInternational Association of Bioethics, on the
Bioethics Commission of the International Union of
Biological Sciences (IUBS), and numerous otherbodies. In 1998 he was the founding President of
the All India Bioethics Association (AIBA). We
shared the common understanding that love wasthe critical message of bioethics, hence theabbreviation “Ai” Bioethics Association, withreference to the Japanese (also the Chinese) word
for love. He was dedicated to cross cultural
understanding and exploration of bioethics,

through his deep Christian faith. He was devoted toChristian service as well as academic life.
Jay was the first Vice-President for India of the
Asian Bioethics Association, and served also as
President of Asian Bioethics Association. He wasformer Professor of Zoology and Former Dean ofLife Sciences, University of Madras, though he had
to follow the mandatory retirement at age 60 years,
from hence he taught at many institutions in India.
Jay passed away while also serving as Visiting
Professor of Zoology and Bioethics (American
University of Sovereign Nations); Visiting Professorof Kumamoto University, Japan; and Founding
Associate Editor of Eubios Journal of Asian andInternational Bioethics (EJAIB).
Through some joint publications, joint
research work since 1993, and spreading bioethics
in India, Japan, Israel, Korea, Turkey, Indonesia,
China and many other countries, there is a deeper
understanding of bioethics. In the joint book,
Bioethics in India, in 1998, we published one
hundred scholars’ papers on bioethics across India.
There are numerous papers of his on the Eubios
Ethics Institute website (www.eubios.info).
Jay, your smile, love,
loyalty,support,wisdom and intellect
will be sadly missed.
May you be together
with dear Hilda, with
so
much
work
accomplished towards
making our world amore ecologically andethical one. I willremember Jay with his
favourite sweater andsmile.
There are also several youtube videos of hisbioethics lectures on:
https://www.youtube.com/watch?v=KvxDyY-Obo0(2003, TRT8, Eighth Tsukuba International
Bioethics Roundtable, Japan)
https://www.youtube.com/watch?v=S6LA-_u9iNY(2005 BBRT1, UNESCO Bangkok)
https://www.youtube.com/watch?v=jDYMV6S7ZE&t=3s(2007 ABC8, Bangkok)
https://www.youtube.com/watch?v=Xggih-rhfTc(2007 ABC8, Bangkok)
https://www.youtube.com/watch?v=x2qJQySZxBA&t=195s(2009 ABC9, Indonesia, includes Prof. Azariah andProf. Umar Jenie, who also passed away in 2017)

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

Obituary to Professor Dr. Jayapaul
Azariah (1939-2017)- Irina Pollard, Ph.D.
Department of Biological Sciences,
Faculty of Science and Engineering,
Macquarie University, N.S.W. Australia, 2109
Email: irina.pollard@mq.edu.au
I feel a need to express my deep sadness at thepassing of a close friend Dr. Jayapaul Azariah – aprecious friendship that reached back over several
decades. Our first social contacts took place at
ABA’s annual meetings during the early 1990s but
soon expanded over a range of other enjoyable
events – so friendship was regularly renewed
during subsequent meetings and as an invited
colleague at Biological Sciences, Madras University.
Being with Jay meant sharing a variety ofactivities that include literature, science,philosophy, bioethics, politics, religion as well as
enjoyable gastronomic life experiences. Writing thishas brought a strong characteristic memory thattook place at a prestigious meeting in Paris where
the projector would not work, but knowingly of mydiscomfort, Jay materialized from the audience andwith one powerful knock my problem was resolved(I now exclusively use power point!)
Jay, I miss your humanity, ethical insights,
positivity and friendship.

39

The world has lost a Bridge
between Bioethics and our Future
Prof. Dr. Umar Anggara Jenie, Apt,
Msc (22 August 1950 – 26 January
2017)- Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign
Nations (AUSN), USA
Secretary, Asian Bioethics Association
Former UNESCO Regional Adviser for Asia and thePacific
The world has lost a leading scientist andbioethicist, and I have lost a teacher and friend.
Professor Umar as he was fondly known tothousands of scholars around the world, was the
public face of bioethics from Indonesia. Umar andhis wisdom, inquiring mind, love and mediation,
will be deeply missed by his colleagues around theworld in many disciplines.
In his position as Chairman of the Indonesian
Institute of Sciences (LIPI), founding Chairman of
the Indonesian National Commission on Bioethics,
and also as Vice-President for South-East Asia, andVice-President for Indonesia, of the Asian Bioethics
Association, Professor Jenie acted as a central
bridge between development of research policy andpractice for the development of bioethics throughAsia and as an interface between Asia and the
Global Community. For a decade he was theinterface of Indonesia and Asian Bioethics, alsochairing the Annual Meetings of the Asian Bioethics
Association in Indonesia in 2008 and 2016. He
attended the annual meetings all around the worldinspiring his colleagues from different countries towork together, and to conduct research of glocal(global and local) relevance. In discussion ofinternational policy, we have to articulate andrediscover values of Indonesia to take a leading rolein a moderate approach to building a global orderthat is fair to all countries, not one dominated by
the former colonial powers and the rich countries,
he believed. Umar always supported and mentored
young scholars to look to themselves and theirculture to find solutions that are enduring andequitable.
Umar also served as a bridge between thenatural science and social science fields that is
critical for sound policy making in the emerging useof science and technology. Several of his
informative talks are available for all to learn fromon youtube; he also, an provided his time freely for
public service as AUSN Visiting Professor in
Medicinal Chemistry and Bioethics. Experts,

40

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

students and the public could all learn from him
how to share wisdom from diverse fields ofgenomics, medicinal chemistry, history, philosophy,
and cross cultural communication and policy
making.
Prof. Jenie’s service to UNESCO as a member of
UNESCO’s Intergovernmental Committee on
Bioethics, as well as in numerous roles as aninternational expert on science, was instrumental
to the implementation of the Universal Declarationon the Human Genome and Human Rights, into
laws in Indonesia, ASEAN and globally. As former
UNESCO Regional Adviser to Asia and the Pacific,
and the former and founding member of UNESCO’s
International Bioethics Committee from New
Zealand, I had the pleasure to work with Umar on
the translation of mere words of governments andthe United Nations into practices that save the livesof vulnerable people, and protect our biodiversity
and biosphere. Future generations will appreciate
the foresight of policies that he helped formulate.
He not only fought to protect people, but also
animals and plants that our world is blessed with.
Umar served us all, and the world was blessed tohave him with us for 67 years – still too short for
his friends and colleagues. God has blessed us tohave Umar among us, and may you rest in peace
sure that your wisdom will continue to inspireothers.

Risks Present in the Cambodian
Surrogacy Business-Masayuki Kodama, Ph.D.
Professor Emeritus at National Institute of Fitness
and Sports in Kanoya, Japan; 13-237-6 Honmachi,
Higashiyama-ku, Kyoto City, Japan, 605-0981
Email: kodama@nifs-k.ac.jp

Abstract

The Thai temporary National Assembly passed theProtection for Children Born through Assisted
Reproductive Technologies Act, 2015 on February
19, 2015. The passing of Thailand’s law regulating
reproductive medicine (surrogacy) was followed byan enactment with the approval of the cabinet andKing Bhumibol Adulyadej in July 2015. Since then,some surrogacy mediation agencies based in
Thailand, including Japanese surrogacy agencies,
have shifted their attention from Thailand to other
Asian countries, such as Cambodia, Georgia andothers. This paper discusses the background of therapid growth of the Cambodian surrogacy industry
as well as the government’s announcement of acomplete ban on commercial surrogacy, and also
the risks inherent in Cambodian surrogacy
business. This paper aims to provide related
information to Japanese surrogacy patients andresearchers in reproductive medicine.

1. Introduction

The New Life Global Network (NLGN) has been in
the midst of international expansion since thepassage of Thailand's Protection for Children Born
through Assisted Reproductive Technologies Act(พ.ร.บ.
คุ้มครองเด็กที่เกิดโดยอาศัยเทคโนโลยีช่วยการเจริญพันธุท
์
Jogyakarta 2008างการแพทย์ พ.ศ. 2558) on July 30, 2015 through thetime of this writing (January 2017). Led by Mariam
Kukunashvili (MD, PhD), the organization has
spread its operations from Thailand, where it
established its initial foothold, to the neighboring
countries of Cambodia, Laos, and Myanmar.1
Following being shut out of Thailand in 2015 due
to national law, the first alternative host country towhich NLGN expanded its operations was
Cambodia, which lacked laws concerning
reproductive medicine, in particular assisted1

Beppu, Japan, 2015

NLGN is a commercial organization that handles egg provisionand surrogacy services. Headquartered in Georgia, thisintermediary agency for reproductive medicine services also has
offices in India, South Africa, Poland, Armenia, and Ukraine,
Mexico, Kenya, and Southeast Asia, and claims on its website tohave helped over 7000 couples and individuals to build theirfamilies. (https://www.newlifeasia.net/)

Eubios Journal of Asian and International Bioethics 27 (March 2017)
reproductive medicine (ART) or surrogacy. Alreadyfacing “more than 50 surrogacy brokers...
advertising online for services in Cambodia” as ofAugust 2016 2 , the Cambodian government
announced a complete ban on commercial
surrogacy in November 2016.3
Despite the proclamation, neither NLGN nor
Japanese surrogacy brokers have suspended
business operations in Cambodia as of the time ofthis writing (January 2017), instead waiting to see
the government's next moves. Such businesses
targeted by the complete ban on commercial
surrogacy can still be easily accessed, but clientsrisk paying an extremely high price for contracting
their services. To what risks are surrogacy patients
exposed as a result of the business priorities of
Cambodian surrogacy agencies? This manuscript
aims to identify the risks inherent in surrogacy
businesses that have spread from Thailand to otherneighboring nations.
2. The Rapid Growth of the Cambodian
Surrogacy Industry, and the Government’s
Announcement of a Complete Ban on
Commercial Surrogacy
Thailand’s interim legislature passed the Protection
for Children Born through Assisted Reproductive
Technologies Act, 2015 on February 19, 2015. It wassoon followed by the Nepalese government, which
took the step of completely banning commercial
surrogacy in the country in September 2015. Somesurrogacy mediation agencies responded to thesemoves by considering alternative host countries toThailand for surrogacy operations: one of these isneighboring Cambodia, which permits surrogacy
treatment and lacks legislation regarding surrogacy
and other forms of reproductive medicine (forexample, the reproductive medicine agency NLGN,
headquartered in Georgia and operating in
Thailand, opened a Cambodian branch in March
2015). Following Dr. Sean Sokteang’s opening of
the country’s first IVF clinic, Fertility Clinic ofCambodia, in September 2014, the country has
experienced rapid growth in the field ofreproductive medicine, and now has 16 surrogacy
clinics. Concerned about the physical and mental
health of Cambodian surrogate mothers andsurrogate children, the Cambodian government
announced a ban on surrogacy in November 2014,
but the activities of surrogacy brokers havecontinued unabated.

2

As Surrogacy Trade Grows, Government Charts Course (The
Cambodia Daily, August 27, 2016).
3
Cambodia bans commercial surrogacy by Xavier Symons[BioEdge, 5 Nov 2016].

41

In addition, the Indian government’s
announcement of measures to completely bancommercial surrogacy drove an exodus of gay
couples to Thailand in 2013. This triggered theinterim military junta of Prayuth Chan-ocha toimplement the Protection for Children Born ThroughAssisted Reproductive Technologies Act, 2015,
whereupon the preferred destinations of gay
surrogacy tourists changed to Nepal and the
Mexican state of Tabasco. The authorities were
bewildered by the legions of gay couples, driven outof country after country in their search forinternational surrogacy, and by the end of 2015
both Nepal and Mexico had adopted measures toban commercial surrogacy by the end of 2015,
ultimately leading these groups to Cambodia.
Two major home countries from which gay
surrogacy tourists have flocked to Thailand since2013 are Australia4 and Israel5. In Australia, neither
surrogacy nor adoption for gay couples isrecognized.
AccordingtotheAustralian
Department of Foreign Affairs and Trade
documentation 6 , the number of Indian-born
children applying for citizenship rose rapidly from
126 in the 2008 financial year (2007-2008) to 519
in the 2012 financial year (2011-2012); among
these, the number of Australians born in India
averaged around 50 per year; similarly, Thai-born
children applying for Australian citizenship jumped
from 294 to 459. In the 2013 financial year, thenumber of Thai-born Australian citizenshipapplications increased even further. The proportionof gay and straight parents in these figures is
estimated to be half and half. Even if they wanted
4

Commercial surrogacy is banned in Australia, but altruistic
surrogacy is permitted for both opposite-sex and same-sex couples.
Passed in Tasmania in 2012, Surrogacy Act No. 34 and Surrogacy(Consequential Amendments) Act No. 31 permit same-sex couples
to have surrogate children as well as opposite-sex couples.
Tasmania passes gay, de facto surrogacy bill (ABC NEWS, August30, 2012).

5 While compensated surrogacy has been legal in Israel following

the 1996 enactment of the Embryo Carrying Agreements Law,applicants are restricted to opposite-sex couples. Moreover,religious law permits surrogacy only when the commissioning
mother and father (whether married or not) as well as the surrogate
mother are Jewish (80% of the Israeli population is Jewish). Israellacks civil marriage: only religious marriage exists, which isordained by rabbis based on religious law. As a result, there aremany de facto married couples in the country who are not legallymarried. In January 2014, Israel’s High Court of Justice recognized
a gay couple’s adoption of a surrogate child genetically related to
one of the parents (High Court orders Israel to recognize gay
adoption of child born through surrogacy; The Jerusalem Post,
January 28, 2014). However, a 2014 amendment bill to the Embryo
Carrying Agreements Law, intended to extend the ability tocommission commercial surrogacy to same-sex and de facto
married couples and single men and women, failed to pass.
6
More parents defy law with overseas surrogacy (The Sydney
Morning Herald, September 14, 2013)

42

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

to, gay couples from Australia and Israel could notchange course and commission surrogacy inGeorgia (the location of NLGN headquarters),
because Georgian law restricts those who cancommission surrogacy to married heterosexual
couples; instead, they headed to Thailand’sneighboring country of Cambodia.
Flooded with the influx of gay couples, theCambodian government gave notice of a coming
crackdown on commercial surrogacy in a
November 11, 2015 article in the Khmer Times7,
warning that “Government officials plan to classify
surrogacy as a form of human trafficking”.8 Despite
the announcement, the number of surrogacy
brokers working clandestinely in Cambodia
continued to increase. Concerned about themassive influx of not only opposite-sex couples, butalso same-sex couples and single persons fromforeign countries seeking surrogacy, the U.N.
Population Fund’s representative to Cambodia
warned in August 2016:“There is currently no legal framework regulating
surrogacy in Cambodia, even though more than 50
surrogacy brokers are advertising online forservices in Cambodia, and Australian couples aretraveling here seeking surrogate services. They needat least a legal framework to avoid malpractices. In
the absence of a legal framework, there is much
more risk of having abuse and malpractice.”9from around the world. At the same time as it pays
off authorities to defend itself from repeated
investigations by the Cambodian socialist
administration, NLGN is fostering new surrogacy
markets in the cities of Vientiane (Laos) andNaypyidaw (Myanmar) as a back-up plan for its
surrogacy program.
Despite their opaque future, parties seeking
surrogacy are directed to these Cambodiansurrogacy clinics by advertisements posted on thewebsites of some Japanese surrogacy agencies(Company A and Company B). NLGN transfers
embryos fertilized via IVF and frozen in Thailand to
Cambodian clinics, where they are implanted inThai and Cambodian surrogate mothers. 10 The
Japanese surrogacy agencies work in a similar way:e.g. Company A inspects chromosomes from frozen
embryos prepared in Japan at a partner Thai clinic
using a next-generation sequencer (NGS). 11 Only
the healthy frozen embryos that pass inspection arethen brought to a partner clinic in Cambodia by aJapanese surrogacy agent, where a local doctor
implants them into surrogate mothers.
What are the risks to the patients of possible
suffering due to the business priorities andattitudes of Cambodian surrogacy agents?

In September 2016, the Ministry of Women’s
Affairs in Cambodia held a conference about theeffects of unregulated surrogacy, and announced it
would take measure to protect the human rights of
Cambodian women and children. On November 3,
2016, the Cambodian government subsequently
notified all medical institutions in Phnom Penh ofan impending complete ban on commercial
surrogacy.
Despite this threat, NLGN claims that there areno laws related to ART or surrogacy regulations in
Cambodia, and therefore surrogacy is not illegal in
the country. Based on this determination, NLGN
continues to recruit and manage surrogate mothersin Thailand and Cambodia, and to act as a mediator
between Cambodian clinics and medical refugees

3. Risks Inherent in the Cambodian
Surrogacy Business
While both Thailand and Cambodia are Theravada
Buddhist countries, there are striking differences intheir attitudes towards the surrogacy industry. In
contrast to Thailand, where there is a strong
tendency to view surrogacy as thamboon (ทําบุญ) or‘a pious act’ for extending a helping hand to people
with reproductive disabilities, this way of thinking
is rare in Cambodia. As a result, a married woman
delivering a child belonging to someone other thanher spouse appears quite abnormal to the average
Cambodian. The national sentiment to stop thesurrogacy industry as a form of prostitution or
child trafficking (i.e. in violation of Article 332 of
the Penal Code: Intermediary between an Adoptive
Parent and a Pregnant Woman referring to “Ban on
Human Trafficking”) has made searching for

7

10

Gov’t to Crack Down on Surrogacy Clinics (Khmer Times,
November 11, 2015)8
The legal basis for this crackdown is Cambodian domestic law:
specifically Article 332 of the Penal Code: Intermediary between
an Adoptive Parent and a Pregnant Woman referring to “Ban on
Human Trafficking”. In addition, Cambodia is party to the UN's
Trafficking Protocol, written in November 2000 to supplement theConvention against Transnational Organized Crime. However, thereality remains that impoverished Cambodian women and children
still become victims of human trafficking.
9
As Surrogacy Trade Grows, Government Charts Course (The
Cambodia Daily, August 27, 2016)

Some companies specialize in the transport of biologicalmaterials. For example, Cryoport, Inc. has recently expanded its
business to not only the Czech Republic, a country with many egg
donors, but also Cambodia, hailed as an alternative to Thailand forsurrogacy tourists. The company uses specialized “cold chain”
technology, a low-temperature distribution system for transporting
gametes and fertilized eggs, whereby cells cryogenically frozen at–151 °C and a calcium silicate sponge soaked in liquid nitrogen areplaced in a Dewar flask and transported to the destination.
11
The Japan Society of Obstetrics and Gynecology does not permit
pre-implantation genetic screening (PGS) or whole-chromosome
NGS.

Eubios Journal of Asian and International Bioethics 27 (March 2017)surrogate mothers a more difficult task for brokers
than in Thailand. Accordingly, the majority ofwomen who undertake surrogate motherhood in
Cambodian society are inevitably divorced womenin financial distress or poor foreign women fromneighboring countries.
Moreover, Cambodian law regards the woman
who gives birth to a child as its legal mother. Thismeans that when a surrogate mother gives birth tothe child of a commissioning couple, she isrecognized as the child's legal mother simply bylending her uterus, even if she lacks a genetic
relationship with the child. This legal situationmeans that commissioning couples from Japan
must jump over several hurdles in order to bringhome a surrogate child genetically related to thembut born in Cambodia between a Japanese father
and a Cambodian surrogate mother. First, thesurrogate mother must undergo legal proceedings
to relinquish her parental rights; second, the childmust be recorded in the couple's family registry,and obtain Japanese citizenship; and third, the childmust be issued both a passport by the Japanese
government and an exit visa by the Cambodian
government. Are these expectations realistic?
Becauseofits
November
3, 2016announcement of a complete ban on commercial
surrogacy to all medical institutions in Phnom
Penh, the Cambodian government is unlikely to beable to publicly issue exit visas to surrogate
children born in violation of it.12 More importantly,
Japan lacks legislation regarding reproductive
medicine, particularly surrogacy; therefore, theEmbassy of Japan in Cambodia cannot issue aJapanese passport to a surrogate child born in
Cambodia if it is to respect the official
governmental positions of both countries. 13 The
legalization of an international adoption system in
Cambodia notwithstanding, the announcement of acomplete ban on commercial surrogacy makes it
impossible not only for the Embassy of Japan in
Cambodia to issue passports to surrogate children
born in Cambodia, but also for the Cambodian
12

Immediately after the distribution of the Notification of aComplete Ban on Commercial Surrogacy on November 3, 2016,
anti-human-trafficking police in Phnom Penh arrested threesurrogacy providers (Tammy Davis-Charles, the Australianfounder of a surrogacy agency, and two Cambodians) on suspicionof violation of Penal Code Article 332: Intermediary between an
Adoptive Parent and a Pregnant Woman referring to “Ban on
Human Trafficking”. (Surrogacy in Cambodia Faces First Official
Charges,
accessed
November
22,
2016
at:
http://www.sensiblesurrogacy.com/ surrogacy-in-cambodia-comesto-end-amidst-arrests/)
13
A surrogate child could potentially be granted Japanesecitizenship and a passport through extra-legal measures, if thegenetic relatedness of the child and its Japanese parent(s) (i.e., thecommissioning couple) could be certified via DNA screening.

43

government to grant exit visas to such children,
since there is no legal system for transferring thesurrogate child to a commissioning couple atpresent. In short, it will likely become impossible
for a surrogate child to be transferred to acommissioning couple.
However, Cambodia is a country where one
can purchase citizenship. Aware of the culture of“legal flexibility” in the country, surrogacy brokers
have traditionally been able to resolve most issues
by bribing authorities in secret. If citizenship can bepurchased, certainly there is a chance that exit visas
can be bought as well. A broker can bribe relevant
Cambodian hospital officials to omit the surrogate
mother’s name from the “Mother” field of asurrogate child's birth certificate, thereby avoiding
any trouble when the commissioning couple
registers its birth at their city office upon returning
to Japan. This workaround is made possible by a
Ministry of Justice directive issued in 1961, whichnotes no special scrutiny for screening married
couples upon their return home with a newborn
child, assuming the women commissioning
surrogacy is under 50 years old.14
The hard reality is that bribery is widely
tolerated in Cambodia, as it is in many poorsocialist countries. This fact and the loophole above
notwithstanding, voices such as the Ministry of
Women’s Affairs are loudly calling for theprotection of the human rights of women andchildren. Combined with the recent notification toban commercial surrogacy, this trend suggests thatthe influence of bribery, traditionally effective inages past, may lose some of its potency. In otherwords, the November 3, 2016 notification must be
taken as a sign that with Cambodian medical
institutions waiting for the government’s next
moves, the ability of surrogate children born there
to emigrate the country is in jeopardy.

4. Conclusion
Despite this, some surrogacy agencies in Japan have
yet to withdraw their Cambodian surrogacy
recruitment advertisements from their website asof the time of this writing (January 2017). Why isthis?
On their websites, Company A and Company B
claim to “perform surrogacy in Cambodia”, lay out
the timeline of each Cambodian surrogacy program,and state that “the child is transferred to themarried couple immediately upon delivery.”
However, even as the Cambodia government
makes explicit its policies to ban commercial
14“[Authorities must] Check the facts of the birth when the motheris 50 years or older.” (Ministry of Justice directive, 1961)

44

Eubios Journal of Asian and International Bioethics 27 (March 2017)surrogacy,
theabove-mentioned
surrogacy
agencies have maintained a uniform silence
concerning the expected risks facing the return of
the surrogate child to Japan. As of January 2017,
Cambodia as a surrogacy destination exposessurrogate children born there to inherent risks.
There is only one word for the behavior of these
Japanese surrogacy agencies which send surrogacyseeking couples to Cambodia while feigning
ignorance of the risks involved: dishonest.
Note: This paper is based on a paper presented at theTenth Kumamoto University International Bioethics
Roundtable, November 2016.

variety of methods. 2. Determine the state offunctioning and the real problem. 3. Plan an
occupational therapy intervention, set long-termand short-term goals, and select and establish thecourse for occupational therapy. 4. Practiceoccupational therapy. Most of the therapy sessions
range from 20 minutes to an hour. 5. Therapists
routinely reevaluate the client (Table1).
Occupational therapists assess the effect oftherapy by comparing previous and current
evaluation data results. If the client completes thegoal, it may be the end of therapy depending on theassessment by the physician. If not, therapists
repeat the process by practicing steps 1 to 5 again.
Table 1: Occupational Therapy Process in Japan

Consideration of Appropriate
Clinical Internships for
Occupational Therapy Students inJapan- Katsuaki Yamano, Ph.D., OTR
Department of Rehabilitation, Faculty of Health
Science, Kumamoto Health Science University
Email: yamano@kumamoto-hsu.ac.jp

1. Introduction

The purpose of this study was to determine theappropriate clinical internship for occupational
therapy students by comparing two different styles:“in charge of client style and clinical clerkship”.
All occupational therapy students in Japan
must practice clinical internship for more than
1000 hours in order to qualify for the national
exam for occupational therapists. Since 1965, a
physical and occupational therapist law has been
established in Japan stipulating that students
practice an internship where they are in charge ofclients and write case reports under a supervisor’s
guidance. However, a number of occupational
therapists have been practicing clinical clerkshipfrom the 2000s onward.
In the clinical education for occupational
therapy students, it is important to compare in
charge of client style with the clinical clerkshipstyle and to consider which of these two styles ofclinical internship appropriately.

2. Occupational therapy process inJapan

Occupational therapists in Japan need prescriptions
from a physician to practice therapy in order tohave compliance with the law. Once they haveprescriptions, occupational therapists complete thefollowing steps: 1. Evaluate the clients using a

0. Prescription by physician
1. Evaluation: interview, observation, collecting
information, and measurement for clients
2. Problem definition: International Classification of
Functioning (ICF) is used to assess the resultsof evaluation and define problems that are to
be targeted through occupational therapy
interventions
3. Intervention planning: goal (long or short-term)
setting; select and establish the course oftherapy.
4. Intervention implementation: verification of theeffects every therapy
5. Re-evaluation: systematically re-collect initial
evaluation data and compare evaluation andre-evaluation data to determine if outcomes
have been met and if discontinuation isappropriate; if not, determine subsequentaction.
6. Completion

3. Legal regulations for clinicalinternship in occupational therapy inJapan
The rules for educational facilities of physical andoccupational therapists (universities and vocational
colleges offering a major in physical andoccupational therapy) are outlined in Article3-2,
notified by the Ministry of Education, Culture,
Sports, Science and Technology and by the Ministryof Health, Labour and Welfare and stipulate thatphysical and occupational therapy students mustpractice a clinical internship of more than 25
credits (810 hours: 45 hours per credit) andcomplete more than two-thirds of the credits in a
medical setting (the Ministry of Education, Culture,
Sports, Science and Technology and The Ministry of
Health, Labour and Welfare, 1966) .

Eubios Journal of Asian and International Bioethics 27 (March 2017)
Besides, the Japanese Association of
Occupational therapists (JAOT) requires aninternship of more than 1000 hours includinginternships of more than six consecutive weeks(Japanese Association of Occupational Therapists,2014). This criterion is based on the international
educational standards of the World Federation of
Occupational Therapists (WFOT). Specifically, it isnecessary to meet these criteria in order to attainthe standard, which is necessary if Japanese
occupational therapists desire to work or study
abroad (Hockinget al. 2002, p.1).
The guide for teaching physical andoccupational therapy at training institutions as
stated by the Ministry of Health, Labour andWelfare lists the following four points asqualifications for the supervisor and the facility ofthe practice of occupational therapy internship:
1) An experienced occupational therapist (clinicalexperience of over 3 years since licensure)supervises the student. 2) It is desirable that thefacility is located near the training school. 3) It is
desirable that the proportion of students tosupervisor is approximately 2:1. 4) The facility
must have adequate equipment to practice theinternship (the Ministry of Health, Labour andWelfare, 1999).

4. The significance and purpose ofclinical internship for occupational
therapy students
The Japanese Association of Occupational
Therapists (JAOT) published the fourth edition ofits guidelines for the occupational therapy clinicalinternship in 2010. JAOT has defined thesignificance and purpose of a clinical internship intheguidelines(Japanese
AssociationofOccupational Therapists, 2010).
According to the JAOT, the significance of aclinical internship is that occupational therapy
students experience occupational therapy practicein the facility and learn the appropriate knowledge,
technology, skills, and attitude in the training
course. The purpose of a clinical internship is foroccupational therapy students to develop anunderstanding of the perspective of the client, as
well as the knowledge, technology, skills, andattitude of a therapist through occupational
therapy planning and treatment, and offer guidanceand support to clients under the supervisor’s
guidance, which will improve their understanding
as a healthcare professional (Japanese Associationof Occupational Therapists, 2010, p.10).

5. Charge of client style internship for
occupational therapy students in Japan45

In the charge of client style internship, occupational
therapy students practice client-based occupational
therapy and write case reports under a supervisor’s
guidance.
The JAOT defines the goals of the clinicalinternship as follows: “occupational therapy
students are able to practice occupational therapy
for general clients under the supervisor’s guidance,
and act as a therapist professionally” (Japanese
Association of Occupational Therapists, 2010, p.17).
In other words, the JAOT recommends aninternship congruent with the charge of client style.
The strength of the charge of client styleinternship is that students are able to repeatedly
experience the occupational therapy process, andto develop the skills of clinical reasoning through arelationship with the client. Additionally, thesupervisor can allocate time for guidance, and,students are able to thoroughly study the client’s
clinical condition.
6. Criticisms of the charge of client styleinternshipThe charge of client style has been practiced inmany occupational therapy training settings inJapan since occupational therapy training courses
began in 1963. There were few Japanese therapists
with a license in those days. Therefore, it wasnecessary to train many therapists. The number ofregistered occupational therapists is insufficient inJapan today to meet the needs of an aging
population. It could be argued that training more
occupational therapists is one of the importantstrengths of the charge of client style.
However, some therapists have criticisms
concerning the charge of client style internship.
Sato, an occupational therapist, notes that the
charge of client style internship has sevenlimitations. 1. Insufficient internship facilities. 2.
Insufficient guidance times. 3. The student’s “powerof clinical reasoning” does not develop whenwriting case reports. 4. The main guidance of thesupervisors is often restricted to the contents ofcase report because they cannot directly lead thestudent’s practice. 5. The number of clients who do
not consent to be treated by students has increased.
6. There is an increase in students’ physical andmental fatigue in practicing the internship all day.
7. Supervisor’s inability to lead (Sato, 2015, pp.6-9).
Nakagawa, a physical therapist, has also
criticized the charge of client style internship for
physical and occupational therapy students, making
the following six points: 1.The supervisor cannot
judge the student’s development in the affective
and psychomotor domains because it is dependent
on the student’s ability to write a case report. 2. The

46

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

student has to practice client therapy despite notpossessing a license. 3. The student is only able toobserve the cases of high-risk clients. Therefore,
the student cannot experience the complete clinicalreality. 4. Clients do not receive enough therapy,
quantitatively and qualitatively, from students. 5.
Supervisors have limited time for students, because
the health service care fee for occupational therapy
has slowly decreased, whereas the number ofclients is increasing. 6. It is understandable thatmany clients do not consent to treatment by thestudent (Nakagawa, 2011a, pp.21-4).
Aida, an occupational therapist, argues thatstudents with little clinical experience are too
nervous and not skilled to practice, and cannot
write case reports that meet supervisor's
expectations (Aida, 2015).

7. Legal interpretation of the clinicalinternship in Japan
It is important to consider the criticism by
Nakagawa that the student with no license
practices therapy on clients in the course of theinternship. Students who have no license topractice therapy are, in their clinical internships, inviolation of physical therapist and occupational
therapist law and of those pertaining to fee forhealthcare services in Japan (Nakagawa, 2011b,
pp.13-4).
The most important law for Japaneseregistered occupational therapists is the physicaltherapist and occupational therapist law
established in 1965. Article 2-4 states, “the term
occupational therapist as used in this act means aperson that is qualified with a license by the
Ministry of Health, Labor, and Welfare, uses thestyle of ‘Occupational Therapist’, and practices in
occupational
therapywithaphysician’sprescription”.
On the other hand, the ministry ordinanceconcerning fee for healthcare services in Japanestablishes that “it is performed under the direct
guidance of the physician, and the occupational
therapy considers it as being performed under aphysician or the monitoring of an occupational
therapist”.
One member of the Diet submitted a written
inquiry in March of 2016 asking if it is violation of
the law for non-licensed students to practicephysical or occupational therapy in internships, andif hospitals and facilities receive a medical fee fromtreatment performed by students. The government
answered that “these practices are not a problem
based on the interpretation of the law, if a physician
or experienced therapist always provides guidance,
ensures client safety, and the client consents topractice by a student, and it is also not a problem if
adequate guidance is provided by a physician orexperienced therapist based on the interpretationof the law.” This is based on an interpretation of theMedical Practitioners Act by the Ministry of Healthand Welfare in 1991 (Ministry of Health andWelfare, 1991).

8. Clinical clerkship style internship for
occupational therapy students
As discussed in the preceding section, it is notagainst the law for a student with no license topractice therapy. However, it is doubtful whether
the student’s therapy is the most effective for theclient as well as therapist (supervisor). Therefore, it
is not surprising even if the client does not consent
to receive therapy from a student. If so, it will not
be possible for the student to practice internship.
Thus, some therapists have emphasized on clinicalclerkship style internship to manage this issue.
The clinical clerkship style internship in Japan
has been practiced by physician since around 2004
(Japan Society for Medical Education, 2005, p.11).
Its prevalence among physicians in Japan has been
affected by the clinical training system, which has
made it a legal obligation in 2004 (Japan Society for
Medical Education, 2005, p.11).
According to the Japan Society for Medical
Education, in the clinical clerkship style internship,
medicalstudents
participate
inmedicalexaminations as a team member. They assist in the
medical examination by engaging in a limited rangeof medical practices under a supervisory
physician’s guidance, and develop the knowledge,
technology, skills, and attitude of a physician. They
have responsibility for the patients because theirpractice is on the medical record (Japan Society for
Medical Education, 2005, p.65).
The clinical clerkship style internship for
physical and occupational therapy was also
introduced around 2000 (Nakagawa & Kano, 2001).
Nakagawa defines that in the clinical clerkship, thestudent participates in the rehabilitation team as an
assistant, which facilitates the development ofprofessional skills and attitudes and ethicalreasoning (Nakagawa, 2011c, p.37).
There are three steps in the practice of theclinical clerkship style internship: 1. Observation:
the student observes the supervisor’s practice andreceives explanations concerning therapy. 2.
Imitation: the student practices therapy under thesupervisor’s guidance. 3. Practice: the student isable to explain risk factors to clients, and practices
therapy individually as permitted by the supervisor(Nakagawa, 2011c, pp.38-9).

Eubios Journal of Asian and International Bioethics 27 (March 2017)
9. Strengths of the clinical clerkshipstyle internship
Nakagawa introduces seven strengths of the clinicalclerkship. 1. The students do not write the casereport, which reduces their physical and mental
exhaustion. 2. Supervisors are freed from checking
the report, and are thus able to devote additionaltime to leading the students and practicing therapy.
3. The student interacts with the supervisor all day
as an assistant, and is therefore always able topractice under supervision. 4. The student is able toexperience various clinical situations, and learn
suitable actions. 5. Supervisors are able to have a
dialogue with students, and effectively guide them.
6. Supervisors are able to ensure adequate therapy
time for the client as well as guidance for the
student. 7. Clients are likely to consent to thestudent being a part of their treatment team(Nakagawa, 2011c, pp.37-41).

10. Criticisms of the clinical clerkshipstyle internship
There are also some criticisms of the clinicalclerkship style internship. Aida mentions that there
are few educational facilities that recommend
clinical clerkships, and many therapists do not havea good understanding of clinical clerkships (Aida,2015).
Although Hanafusa (occupational therapist forphysical dysfunction) and Uda (occupational
therapist for psychiatric dysfunction) practice thethree-step clinical clerkship, there are several
points that differ because of the difference inclinical specialization. They demand that students
produce a planning report and occupational
therapy summary for the client and case conferencematerial for the other team staff if necessary(Hanafusa 2016; Uda 2016).

11. Discussion

It can be a valuable experience for students topractice current occupational therapy processes
through the charge of client style internship.
However, this style may cause the students to use
their energy unproductively in producing casereports. Most of the students are not skilled enoughto practice occupational therapy with the little
clinical experience they gain. For example, thesupervisor’s guidance time with the student islimited to the time allowed practicing therapy as
set by the healthcare service fee (max 60 minutes).
Therefore, they have minimal discussion withclients and therapists, resulting in insufficient time
for guiding the students while providing therapy
for many clients. In this situation, the students do
not have adequate time to acquire the necessary

47

skills as therapists and to write case reports during
the clinical internship. As a result, students are notable to learn about the professional responsibilities
of an occupational therapist.
In comparison, clinical internship enables
students to enhance their professional qualities andprovides the experience needed to gain the true
meaning of the occupational therapy profession.
Considering these viewpoints, the clinical clerkshipis a better style of clinical internship than the
charge of client style for occupational therapy
students. However, the clinical clerkship style also
has some problems. Some of the students arelimited to observation or imitation in theinternship. There are reasons for this: 1. Many of
the occupational therapy students cannot act in theinternship because they are not skilled enough. 2.
The supervisor does not set internship planningand may not have a strategy for leading because ofa lack of understanding of the clinical clerkship. 3.
The educational facility may not establish
attainment goals for every step. The students may
lose focus if their only purpose is to earn enoughcredits, and they cannot acquire occupational
therapy clinical thinking skills if they do not write
case reports. In other words, it is easy for theinternship to become a mere label rather than aproductive experience.
Supervisors need a better understanding of theclinical clerkship type of internship. Furthermore,lecturers in the occupational therapy training
setting and supervisors need to cooperatively plan
the clinical internship, and explain to students the
purpose, passing level, and contents of the clinicalclerkship style internship.

12. Conclusion

It is desirable that occupational therapy students
practice more in the clinical clerkship style during
the clinical internships. However, it is hard to saythat supervisors have an adequate understandingof the needed clinical clerkship. There needs to be asupervisor instruction course concerning theclinical clerkship style in the future.
Note: This paper is based on a presentation at theTenth Kumamoto University International Bioethics
Roundtable, November 2016.

References

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rinsyoukyouiku toha (What is clinical education basedon clinical clerkship?). JJOT 49 (11): 1114-20.
Hanafusa K. 2016. rinshoujissyuusidousya no tachiba
kara, shintaisyougai ryouiki (kyuuseiki) (From a pointof view of a supervisor – specialized for physical

48

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

dysfunction (acute stage)). Japan Journal of
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Hocking C, Ness NE. 2002. World Federation of
Occupational Therapists Revised Minimum Standards for
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Therapists.
Japan
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Medical Education. 2005.
shinryousankagata rinnshoujissyu gaido (Guideline ofclinical clerkship style internship), shinoharashuppansya.
Japanese Association of Occupational Therapists. 2010.
Sagyoryoho rinshojissyu no tebiki dai4pan (Theguideline of occupational therapy clinical internship,
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Japanese Association of Occupational Therapists. 2014.
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therapist).
(Accessedon2017.1.30)
http://www.jaot.or.jp/wp-content/uploads/2013/
12/OTmimimumstandard-3nd1.pdf>.
Ministry of Health and Welfare. 1991. Rinsyojissyu
kenntou iinkai saisyu houkoku 2 (The Final Report by
the committee on consideration of clinical internshipfor physician 2). (Accessed on 2017.1.13)
http://www.mext.go.jp/a_menu/koutou/iryou/__icsFil
es/afieldfile/2013/03/13/1329799_02.pdf >Ministry of Health, Labour and Welfare. 1999. The guideto teaching for physical and occupational therapy
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Ministry of Health, Labour and Welfare. 2016. Heisei 28
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tanntosei jissyu no houkai (Inspection of clinicalinternship- collapse of the charge of client style).
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Kurinikarukurakusippunosusumedai2han,(Recommendation of clinical clerkship for therapist
education, second edition), Miwa-shoten, pp.20-5.
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rinshojissyu no kiki (a crisis of clinical internship in the
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no susume dai2han, (Recommendation of clinicalclerkship for therapist education, second edition),Miwa-shoten, pp.37-42.
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nanoka? (Why is clinical clerkship style internshipnow?) Aomori sagyoryoho kenkyu 24 (1): 5-15.
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JJOT 50 (3): 272-8.

Lack of ethical reasoning in theinnovation narrative ofOccupational Therapy andOccupational Science literature- Samantha Sirianni,
Cumming School of Medicine, University of Calgary,
Calgary T2N4N1, Alberta, Canada
Email: smsirian@ucalgary.ca-Gregor Wolbring
Department of Community Health Sciences,
Cumming School of Medicine, Stream of Community
Rehabilitation and Disability Studies
Cumming School of Medicine, TRW building 3D31
University of Calgary, 3330 Hospital Drive NW,
Calgary, Alberta, Canada (Correspondence)
Email: gwolbrin@ucalgary.ca

Abstract
Occupational therapy and occupational science are
two fields that are impacted by innovations and areseen as innovative. Ethical reasoning is seen as
essential for guiding innovative processes such as
the development of new scientific and technologicalproducts. At the same time it is reported that
ethicists “lack the appropriate intellectual tools forpromoting deep moral change in our society” andthat members of the public such as parents ofchildren with disabilities do not necessarily use
ethical theories and ethical reasoning to highlighttheir problems. The purpose of this study was toinvestigate how the fields of occupational therapy
and occupational science engage with ethics within
their innovation-covering academic literature andwhether occupational therapy and occupational
science were mentioned in academic journals that
contained words starting with “ethic” in the title.
We found little conceptual engagement with ethics
principles and no employment of ethical theories in
the academic literature covered. We also foundlittle engagement with occupational therapy or
occupational science in academic journals that

Eubios Journal of Asian and International Bioethics 27 (March 2017)contained words starting with “ethic” in the title.
Our findings are another example of the limited useof the term ethics and limited uptake of ethicalreasoning using ethical theories giving further
weight to the concerns Sherwin voiced.

Key words: ethics, ethical theories, ethicalreasoning, innovation, science, technology,
occupational therapy, occupational science;
1. Introduction

Occupational therapy and occupational science
focus on improving the health and well-being ofpeople by enabling people to participate in theactivities of everyday life [4]. Occupational
therapists are responsible to remain current withnew developments in the profession and tomaintain excellence in their practice [5].
Occupational therapy and occupational science as
fields and occupational therapists are continuously
impacted by scientific, technological and innovation(STI) developments[6]. Ethical theories and ethicalreasoning are employed with local and global
scopes when one discusses for example thegovernance of scientific, technological andinnovation (STI) developments [2,7-25].
Ethics is about what one ought to do. However,as Sherwin stated, “we [ethicists] lack theappropriate intellectual tools for promoting deep
moral change in our society” ([1] quoted in[2]).
Furthermore one study revealed that members of
the public such as parents of children withdisabilities do not use ethical theories and ethicalreasoning to highlight their problems [3]. Our study
investigated how the fields of occupational therapy
and occupational science engage with ethics within
their academic literature covering innovation andwhether occupational therapy and occupational
science were mentioned in academic journals
containing words starting with “ethic” in the title.
1.1. Occupational Therapy andOccupational Science
According to the World Federation of Occupational
Therapy, “Occupational therapy is the art andscience of enabling engagement in everyday living,
through occupation; of enabling people to performthe occupations that foster health and well-being;
and of enabling a just and inclusive society so thatall people may participate to their potential in thedaily occupations of life” [4].
Occupational therapists work with people andcommunities “to enhance their ability to engage inthe occupations they want to, need to, or are
expected to do, or by modifying the occupation or
the environment to better support their49

occupational engagement” [26]. In recent years
occupational therapy added concepts such as
occupational
justice[27-29],ecologicalsustainability of occupations [30], occupational
satisfaction [31,32], occupational enablement [33]and other areas [34] to its focus. According toYerxa, one of the founders of the field occupational
science in the 1990’s, occupational science is an
emerging basic science which supports the practiceof occupational therapy [35]. Occupational science
is seen to assist in developing the understanding of
the occupational nature of humans [36,37] as amethod of achieving social justice and social reform[38] and it engages with many occupational
concepts (Table 3 in [39]).
1.2. Occupational Therapy, Occupational
Science and Innovation
The fields of occupational therapy and occupational
science both have narratives around innovation.
For example, innovation is listed as one value of theCanadian Association of Occupational Therapists[40]. The Canadian Association of Occupational
Therapists has an award for innovative practicewhich is given for “exceptional leadership andinnovation in the application of evidence-based
principles of occupational therapy to clinicalpractice” which includes “client service, consumer
advocacy,
policydevelopment,
community
development, education and/or fieldwork” [41]. On
the webpage of the Canadian Association of
Occupational Therapists it is stated that the“nominees shall have had a positive impact onclients, the community and/or the advancement ofoccupational therapy clinical practice” [41].
Occupational scientists are seen to “study ways ofmeasuring participation, develop new andinnovative methods of intervention to help
individuals engage in activities, and examine theimpact of participation on an individual’s healthand well-being” [42].
1.3. Code of Ethics and Occupational
Therapy Organizations
Codes of ethics are documents that are developed
to give guidance to organizations and groups
working under them. The Canadian Framework for
Ethical Occupational Therapy Practice addresses
the ethics principles of autonomy, beneficence, nonmaleficence, and justice [43]. Ethics is used as anumbrella term, combining elements of identity andknowledge, as an everyday way of behaving andwhat each person values and considers important[43]. The framework primarily discusses theprofessional ethical conducts that are important for
occupational therapists to follow in a way that is50

Eubios Journal of Asian and International Bioethics 27 (March 2017)“technically proficient and honors the stories andlived experience of both the therapist and theclient” [43].
Occupational therapists are furthermore
expected to be courageous, competent, mindful,respectful, sensitive, and reflective when they are
working with clients, as occupational therapists areaccountable to those they serve and to society [43].
According to the World Federation of Occupational
Therapy Code of Ethics, occupational therapists
must maintain many personal attributes such as
integrity, reliability, open mindedness, and loyalty[44] . Occupational therapists must respect theirclients and their unique situation as well as notdiscriminate against their clients and keep theclient information confidential [44]. Occupational
therapists must be able to collaborate with otheroccupational therapists as well as other professions[44]. A combination of knowledge, skills andevidence must be acquired by the occupational
therapist to help their clients in the best way as
well as to improve their professional field [44]. It
also states that the occupational therapy field has tobe promoted to the public, other professionalorganizations and government bodies in an ethicalway [44].
1.4 Ethics and Innovation
There are many discourses around innovation andethics for example medical technology [45],inclusive innovation [46], critical social innovation[47], tripartite innovation for global health [48],sticky ethics and corporate responsibility [49],ethical considerations in the innovation business[50], the politics of blood ethics [51], the ethics ofclinical innovation in psychopharmacology [52],legal ethics and technological innovation [53],ethical technology management and innovation[54], and the ethics of innovation [55]. 93% of thearticles in the Journal of Responsible Innovation
mention words starting with ethic [56]. Empiricalethics and responsible innovation are linked [57]and ethics education is seen as useful for
responsible innovation [58].
Given that ethical reasoning is seen as essential
for guiding scientific, technological and innovation
developments, given Sherwin’s concern that
ethicists “lack the appropriate intellectual tools forpromoting deep moral change in our society” ([1]quoted in[2]) and that members of the public suchas parents of children with disabilities do not per seuse ethical theories and ethical reasoning tohighlight their problems [3] and given thatoccupational therapy and occupational science see
innovation as important for their respective fields,
the purpose of this study was to investigated how
the fields of occupational therapy and occupational

science engage with ethics within their innovation
covering academic literature and whether
occupational therapy and occupational science
were mentioned in academic journals that
contained words starting with “ethic” in the title.

2. Data Source and Sampling
We employed three approaches accessing three
types of sources to generate descriptive
quantitative and qualitative data answering thequestions the study posed.
Approach 1: We accessed five occupational
therapy journals of different backgrounds(American Journal of Occupational Therapy, British
Journal of Occupational Therapy, Canadian Journalof Occupational Therapy, Scandinavian Journal of
Occupational Therapy, and Hong-Kong Journal of
Occupational Therapy) and the Journal of
Occupational Science.
We searched the website search engines of thefive occupational therapy journals and theoccupational science journal for the term
“innovation” in the abstracts of articles on May 5,
2015. We identified n=121 articles from theAmerican Journal of Occupational Therapy, n=129
articles from the British Journal of Occupational
Therapy, n=142 from the Canadian Journal of
Occupational Therapy, n=19 from the Scandinavian
Journal of Occupational Therapy and n=6 articles
from the Hong-Kong Journal of Occupational
Therapy and n=41 articles from the Journal of
Occupational
Science.
The
articlesweredownloaded as PDF and uploaded into Atlas-Ti. 7, a
qualitative analysis software, for descriptive
quantitative and qualitative content analysis.
Approach 2: We accessed three academic
databases (EBSCO All - an umbrella database thatconsists of over 70 other databases including
Medline; Scopus and Web of Science) that containjournals that cover a wide range of topics. These
databases include many journals that haveoccupational therapy in the title of the journal suchas: British journal of occupational therapy; American
journal of occupational therapy; Australianoccupational
therapyjournal;Physical&occupational therapy in pediatrics; Occupational
therapy in health care; Physical & occupational
therapy in geriatrics; Canadian journal ofoccupational therapy; Scandinavian journal ofoccupational therapy; Occupational therapy inmental health; Indian journal of physiotherapy &occupational therapy;
Occupational therapy
international; Indian journal of occupational
therapy; Mental health occupational therapy;
Occupational therapy journal of research; SouthEubios Journal of Asian and International Bioethics 27 (March 2017)
African journal of occupational therapy; New
Zealand journal of occupational therapy; Journal ofoccupational therapy, schools & early intervention;
Hong Kong journal of occupational therapy; Irish
journal of occupational therapy and Physiotherapy &occupational therapy journal.
We searched (May 19, 2015) the threeacademic databases for the terms “occupational
therapy” and “innovation” in the abstract (EBSCOALL), abstract, title, keyword (Scopus), Web of
Science (topic: meaning Title, Abstract, Author
Keyword and Keywords Plus®) limiting thesearches to articles, editorial material, review andproceeding papers (Web of Science); review, article,
conference paper, editorial (Scopus) and scholarly
peer reviewed journals (EBSCO ALL). Of thepositive hits n=108 were duplicates from thesearch conducted in Approach 1 and discarded. The
n=71 new articles found were downloaded as PDF
uploaded into Atlas-Ti a qualitative analysis
software for descriptive quantitative andqualitative content analysis.
Approach 3: We searched for the presence of theterms “occupational science” and “occupational
therapy” in the abstract of articles from journals
with words starting with “ethic” in the title of thejournal that are listed in EBSCO All and Scopus(March 3, 2016). We did not use Web of Science as it
does not generate a hit count for all publications
with words starting with “ethic” in the journal title.

3. Data Analysis

To obtain descriptive quantitative data weemployed three approaches.
Approach 1: We searched all the downloaded
articles obtained as described under section 2.1.
Approaches 1 and 2 for terms and phrase
containing words starting with “ethic” and using
the advanced search feature of the software Adobe
Acrobat X Pro to record the numbers of how often agiven term or phrase linked to ethics was present ina given article and in how many articles (Table 1).
Approach 2: We searched all the downloaded
articles obtained as described under section
approach 1 and 2 for containing words startingwith “ethic”, the following n=14 ethics terms:“value”, “philosoph*”,“justice”, “moral*”,“autonomy”, “bioethics”, “dignity”, “care ethics”,“virtue ethics”, “feminist ethics”, “human ethics”,“public health ethics”, “beneficence”, “maleficence”
and n=19 ethical theories: “Kant”, “Socialist”,“Egalitarian”, “Moral Relativism”, “Individual
Relativism”, “Cultural Relativism”, “Psychological
Hedonism”, “Psychological Altruism”, “Female Care
Based Ethics”, “Virtue Theories”, “Samuel

51

Pufendorf”,“Rights
Theory”,“WD
Ross”,“Consequentialism”, “Deontology”, “Utilitarianism”,“Preference Utilitarianism”, “Libertarian” and“Feminist Approach”. The 34 terms were takenfrom Beauchamp and Childress’ 1979 paper“Principle of Biomedical Ethics” [59] as well asencyclopedia or web sources [60-63].
We used again the advanced search feature of
the software Adobe Acrobat X Pro to record thenumbers of how often a given term or phrase
linked to ethics was present in a given article and in
how many articles (Table 2). We also used theadvanced search feature of the software Adobe
Acrobat X Pro to record how often a term linked to
ethics was present in an article within 20 words
from a word starting with “inno” (Table 2).
Approach 3: We recorded how often the terms“occupational science” and “occupational therapy”
were present in the abstract of articles fromjournals with a word that starts with “ethic” in thetitle of the journal that are listed in EBSCO All and
Scopus (March 3, 2016) (section 3.1.3.).
The descriptive quantitative data generated by thethree approaches was generated by both authors
and no discrepancy was evident in counts obtainedby the two authors.
To obtain qualitative data the downloaded
articles were auto-coded for words starting with“inno” which generated n=1075 hits and for words
starting with “ethic” which generated n=1442 hits.
A co-occurrence code was then generated thatindicated the co-occurrence of the two words
within 20 words (n=21 quotes). A thematic analysis
was performed on the co-occurrence (n=21 quotes)
and the n=1442 ethics-related quotes. Bothresearchers performed the analysis and results
were compared between the researchers. No
dispute occurred partly due to the few articles thatlinked content to ethics and related terms.

4. Limitations
Only documents that were in English wereconsidered. We did not cover all the occupational
therapy journals in existence and all academic
databases that might have articles that coveroccupational therapy and occupational science. As
such our conclusions are linked to the sources
covered and cannot be generalized.

5. Results
In a first step we generated descriptive quantitative
data on which phrases were linked to words
starting with “ethic” (Table 1), which of the n=34
ethics terms mentioned in the section 2.1 were
present in the sources covered (Table 2) and how

Table 1. The hit count and the article count for each ethics discourse term, ordered by “Number of Articles in
OT Journals” (Second column)
Phrase linked to words
starting with ethic

Ethic*
Ethics approval
Research ethics
Ethics committee
Code of ethics
Ethical consideration
Ethics board
Ethically
Ethical dilemma
Work ethic
Ethical implications
Ethics review
Ethical principles
Ethical obligation
Ethical guideline
Ethics permission
Ethical concern
Ethical decisions
Ethical reasoning
Professional ethics
Ethical standard
Ethical practitioner
Ethical conduct
Ethical question
Ethical belief
Ethical use
Ethical constraints
Protestant Ethics
Interactive ethics
African Ethics

OT Journals
Hit Counts

1442
530
212
225
98
34
16
25
14
11
13
11
8
7
8
6
5
6
9
3
5
2
2
1
1
1
0
0
0
0

OT Journals
Number of
Articles(n=417)
160
70
53
46
32
18
15
13
12
8
8
7
7
7
7
6
5
5
4
3
3
2
2
1
1
1
0
0
0
0

often occupational therapy and occupational
science show up in ethics journals.
Quantitative Data: Table 1 shows how the term
ethics was used in the n=417 occupational therapy
and n=41 OS articles. Words and phrases
containing words starting with “ethic” werementioned n=1442 in n=160 occupational therapy
articles and n=56 in n=16 OS articles. “Ethicalapproval” had the highest counts with n=530 in
n=70 occupational therapy articles.
Table 2 shows with the hit count and thearticle count for each of the n=34 ethics discourse
terms. It demonstrated that many ethical theories
were not employed in the literature investigated,
and also that key bioethics principles such as
beneficence and maleficence were not employed.
Mentioning of Occupational Therapy andOccupational Science in Ethics Journals: Of the
45,588 articles found in the databases that havewords starting with “ethic” in the title of journals,
n=5 articles mentioned occupational therapy in theOS
JournalHit
CountsOS Journal
Number of
Articles(n=41)

56
1
2
0
0
0
3
3
0
13
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
1
2
3
3

16
1
2
0
0
0
3
2
0
2
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
1
2
1
1

Database Journal
Hit Counts(excluding OT
journals alreadycovered)
45
6
1
4
3
1
0
1
0
0
0
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0

Database Journal
Number of Articles(n=71)(excluding OT
journals alreadycovered)
23
6
1
3
2
1
0
1
0
0
0
1
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0

abstract. Not one article mentioned occupational
science in the abstract.
Qualitative Analysis: Most of the quotations
generated for the articles uploaded into Atlas Ti7
contained content that did not engage in ameaningful or conceptual way if at all with then=34 ethics-related terms in question. As such we
only recap here our findings for the quotes
generated with words and phrases containing
words starting with “ethic”. First, we will discuss
the ones not linked to innovation within a 20-word
distance, and then we will discuss the quotations
that co-occurred with “inno*”.
Ethic* and Occupational Therapy: Althoughn=1442 quotations were generated for words
starting with ethic most of the quotations reflect abureaucratic use of words containing ethic, such as
ethics approval or using a term without giving
content. Only seven articles were found to havesome content.

Table 2. The hit count and the article count for each of the n=34 ethics discourse terms
Term

OT
journals
Hit Counts

OT
journals
Numberof
Articles(n=417)

Number of hits/
articles withterms inproximity (20words) of term
innovation in the
database OT
articlesethic*
Value

1442
1978

160
269

21/8

Philoso*721

Harm
Autonomy
Justice
moral*
Dignity
Beneficence
Maleficencecare ethics
virtue ethics
feminist ethics
public healthethicsbioethics

216
185
177
151
49
0
0
2
0
0

146

OS
Hit
CountsOSjournal
Numberof
Articles(n=41)

Ethics Concept
56
16
78/21
254
33

105

22

40
8
64
35
4
0
0
0
0
0
0

15
4
14
17
3
0
0
0
0
0
0

2/1

Number ofhits/
articlewithterms inproximity(20
words) of
term
innovationin the OS
journalDatabase
Hit
Counts(n=71)

Database
OT
Numberof
Articles(n=71)

Number ofhits/
articlewithterms inproximity(20
words) of
term
innovationin thedatabase
OT articles

0
5/2 none
linkingvalue with
innovation
2/1 (notlinking
philoso toinnovation
0
0
0
0
0
0
0
0
0
0
0

45
495

23
61

0
0

236

35

0

110
26
74
67
4
0
0
0
0
0
0

29
11
18
22
4
0
0
0
0
0
0

0
1
0
0
0
0
0
0
0
0
0

0

0

0

0

0

0

0

0

92
76
58
61
22
0
0
2
0
0
0

0
13/6
2/1
4/2
0
0
0
0
0
0

21

3

0

Egalitarian

7

6

0

0
0
Ethical Theories
3
2

Socialist
Hedonism
Libertarian
Feminist
ApproachMoral Relativism
Individual
Relativism
CulturalRelativism
Psychological
Hedonism
Psychological
Altruism
Female Care
Based Ethics
Virtue Theory
Samuel Pufendorf
Rights Theory
WD Ross
Consequentialism
Deontology
Utilitarianism
Preference
Utilitarianism

0
1
1
1

0
1
1
1

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

4
0
0
0

3
0
0
0

0
0
0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

1

1

0

1

1

0

4

4

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0

0

0

54

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

Abernethy, in her 2010 article The assessment
and treatment of sensory defensiveness in adultmental health: a literature review, stated that noneof the articles in her literature review covered
ethical implications [64]. Two articles engaged withthe phrase “ethical reasoning”. One linked issues ofsustainability
withoccupational
therapy
philosophy and discusses how employing asustainability lens with professional reasoning canhelp practitioners integrate sustainability into theirpractice [65]. The authors stated: “In addition toaddressing issues related to individual client care inour day-to-day practice, occupational therapy
practitioners should also consider ethicaldimensions of the issues by utilizing thesustainability lens discussed in this paper. This lens
encourages practitioners to focus on theconsequences of our actions and consider ourduties, responsibilities, and the morally correct
action to be taken, which is an extension of ethicalreasoning” [65].
Wendy Wood’s article covered the process ofcurriculum redesign of an occupational therapy
Master’s degree in which Wood engages with theterm “ethical reasoning”. Wood states “Ethicalreasoning is defined in the curriculum as processesof enacting the highest standards of ethical conductand of generating solutions to problems on thebasis of a systematic study of morality. The article
examined current threats to the field “in light ofpast compromises that weakened occupational
therapy’s sociopolitical position and diminished its
power to meet the occupational needs of people
and society” [66].
Taff et al assessed “how contemporary
challenges and a need for ethical identity require aphilosophical shift”[67] and their article has asection called “Occupational Rights and Human
Dignity: Defining Ethics and Accountability” [67].
The phrase “ethical considerations” was mentioned
in n=25 articles. However, the phrase was mostly
linked to ethics approval. Again, Taff et al provide
some content: “There is some debate in recent
years about the core values as well as the ethicalconsiderations in the definition and practice ofoccupational therapy” [67]. Ethical dilemmas werebrought to light in one paper where they are“related to an inability to offer new technology to
all clients due to funding short falls” [68] whereby
the lack of access was seen as being able to beaddressed and resolved through public opinion andclient experience [68].
Vincent reported on a survey saying thatpeople say ethics is important [69]. However, it was
not explained what is meant with ethics. Although
the term “ethical implication” was mentioned in
n=8 articles in only one case was it not linked to

ethics approval. Castro et al. stated “As culture isdifficult to define, and has political and ethicalimplications, an investigation into its usage iswarranted” [70] and flagged the possibility that “alack of critical insight into professional knowledge
increases the risk that occupational therapy willremain satisfied with the current understanding of
culture, based on the dominant knowledge. The
discipline could fail to address the political, ethical,
and theoretical issues required to reach thetargeted diversity in its practice” [70].
Taff et. al in their article The Accountability–
Well-Being–Ethics framework: A new philosophicalfoundation for occupational therapy, engage with
Rortyian thoughts and they have “particular
relevance in occupational therapy, where the focus
on possibilities and local meanings resonatesheavily with people’s lived experience. Hiscontextualism differs from most philosophicalperspectives because it is not concerned with great
truths. Instead, it is a ‘‘lowercase’’ philosophy that
ponders the joys, dilemmas, and improvement ofdaily life. The discoveries of science are crucial tosupport the continued growth of professional
knowledge. No less important, though, is thephilosophical view of the person as an active agent
in achieving a good life, and it is equally critical that
this facet of occupational therapy be sustained tofacilitate both local and global influence. The
person-centred philosophy must be nourished, and
it is here where Rorty plays a key role. Rorty brings
philosophy out of the realm of scientists andacademics and presents it as a tool for solving
problems and achieving equity in everyday
experience. This ‘‘lower-case’’ philosophy requires
collaboration, promotes capabilities, and isavailable to everyone. As such, it is a valuable ally tooccupational therapy as the profession seeks ways
to address the new challenges of changing healthcare policies, globalization, and sociopolitical andclimate-driven determinants of health. The
Rortyian concepts of hope, solidarity, andcontingency provide new and needed concepts
upon
which
occupational
performance,
participation, and well-being can be addressed as
we move through the 21st century” [67].
Ethic* and Occupational Science: Words startingwith ethic were mentioned in n=16 articles n=56
times with n=6 articles having some content. One
article stated that occupational science needs toengage with ethical considerations in order for it to
be a socially responsible [71].
According to Rudman, it is important toconsider “how occupational science is ethically,
morally and politically responsible for theknowledge it generates” which “challenges

Eubios Journal of Asian and International Bioethics 27 (March 2017)
occupational scientists to redefine the boundaries
between ‘professional’ (sometimes framed as
applied) and ‘scientific’ (sometimes framed as
basic) knowledge and practices” [72] and the“broader dialogue addressing the types ofknowledge production falling within the domain
and practices of occupational science is essential tooptimize relevance and ethical and social
responsibility” [72]. Willis link Protestant ethics tosocial history of deadlines [73].
Halahan states “competence can be regarded
as a process*not merely as an outcome*and used toenrich practices by opening the arena of humanaction to its ethical, or value-laden, nature.
Participants in occupation become agents of safe,
effective, lifegiving, meaningful pursuits, not meretechnicians of action, because competence consists
as much in people’s ability to articulate why they
act the way they do as it does in their capacity to act
in the first place” [74]. In an article by Elelwani
Ramugondo, an ethics idea governing humanengagement called Ubuntu, an interactive ethics
also called African ethics, is discussed as it is moreof a community based ethics rather than justconcerning the individual [75]. In this article theUbuntu “raises consciousness around the
responsibility of both individuals and communities
to allow meaningful existence for all” [75]. This
form of ethics governing is concerned with howeach individual impacts other individuals [75].
Dickie et al make a case for “Transactional
occupational science based on Dewey and his allies”
which they assert is “a solid foundation on which toplace the concept of occupation” as it “provides aphilosophical basis for the importance ofoccupation in everyday life and because it “enables
occupation to be directly related to a wider range ofexperience and inquiry, from ethics to cultural
analysis to political issues such as occupational
justice” [76].
Ethic* and Innov*: N=21 quotations in n=8
occupational therapy articles were generated forthe presence of “inno*” and “ethic*” within 20
words. All but two articles used the term “ethics
approval” and did not use ethics in relation to
innovation. No article was obtained for “inno*” and“ethic*” within 20 words distance in theoccupational science articles.
As to the two occupational therapy articles
mentioning “ethic*” and “inno*” within 20 words
distance; Hoffmann in a 1979 article Continuing
Education: An Answer to Professional Obsolescencerecognized “that new innovations have also
fostered a host of problems” [77], stating further
that “Organ transplants, for example, have opened a
Pandora's Box in terms of ethical questions. The

55

debate of prolonging life by mechanical means
when there is virtually no hope for recovery, has
fostered a major debate of the right to die issue. A
good example of this situation is the Karen Quinlan
case in New Jersey. Another example is biologicalresearch on recombinant DNA. It is now possible
for scientists to combine genetic material fromdifferent molecules and generate biological matterin the laboratory that are not found in nature.
Another example is the recent debate concerning
test tube fertilization” [77]. However, Hoffman does
not explicitly state what the ethical issues are andhe does not employ ethical reasoning to discuss
some of the specific innovations highlighted.
Anita Atwal’s paper stated that “The challenge
for action researchers is to act ethically. Wheninstigating change in the health service,investigators must let professionals drive change
innovations even though the investigator may findhimself or herself challenging assumptions. Action
researchers have to ensure that the quality, valueand honesty of their inquiries are not jeopardisedby unrecognised bias and influence” [78].

6. Discussion
Based on the articles investigated, our findings
suggest that the occupational science andoccupational therapy academic literature aroundinnovation did not engage with ethics in a
substantial matter such as employing ethicaltheories or ethics principles. Further, we foundlittle engagement with occupational therapy and noengagement with occupational science in ethics
journals searched. We posit that this is problematicgiven that occupational therapy and occupational
science is seen to be in constant need to innovate[40-42] and given that science and technology
products are an area of interest to occupational
therapy and occupational science [79-86], productsthat constantly are influenced by advancements inscience and technology. Furthermore, advances inscience and technology are seen as innovative andthey influence innovation discourses including
social innovation. As Jarvis states: “As stated in our
Code of Ethics, it is our obligation to keep up to datewith changes in our field” [87]. This quote is trying
to show the connection that ethics has with
innovation in the occupational therapy field [87].
It is also a problem from the perspective of the
ethics field. Ethicists want to influence social andpolitical change; but some see problems with doingso. Sherwin recently stated: “We lack theappropriate intellectual tools for promoting deep
moral change in our society. To find ways ofaddressing these difficult questions, we need tolearn about the levers of social and political change.

56

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

We probably need also to develop skills incommunicating effectively with the public and toengage in some version of political lobbying. In
other words, we must develop new types ofunderstanding and new ways of practice” ([1]quoted in[2]). Our findings provide evidence for the
problem Sherwin outlines. Ethical theories, one of
the main tools used in academic ethics discourses
to justify certain reasoning and conclusions are nottaken up by the occupational therapy andoccupational science academic literature. Given ourfindings, it is reasonable to assume thatoccupational therapists do not employ ethicaltheories in their reasoning.
Sherwin asks for the re-orientation of theoretic
tools used in bioethics to guide the field in a new
direction [1]. She asks for adopting an ethics of
responsibility; exploration of the responsibilities ofvarious kinds of actors and relationships among
them and the expansion of the types of participants
engaged in bioethics ([1] quoted in [2]). We positthat occupational therapy and occupational sciencebased on their focus on occupation deal with many
issues that raise ‘ethical issues’. As such we positthat the active and knowledgeable involvement ofoccupational
therapyscholars,
students,
practitioners and occupational science scholars andstudents is fitting Sherwin’s demand. This inclusion
however demands that occupational therapy
scholars,
students
andpractitioners
andoccupational science scholars and students employ
ethical theories and ethical reasoning beyond what
we found which we posit means that a curriculum
change is needed that trains occupational therapy
and occupational science students how to use
ethical theories and ethical reasoning. Indeed given
certain emerging science, technology andinnovation development such as using robots for
employment [88] it seems fruitful to develop acommunity of practice around an “ethics ofoccupation” a phrase which so far only has 41 hits
in Google scholar whereby the focus is not on jobs
and being busy but occupation of ones space byothers.
To develop an ethics of occupation as in job,
work, and being busy fits with the goal ofoccupational therapy and occupational science. It
also is an pressing issue, given anticipated trends inrobotics [88], 3D printing [89-91] and molecular
manufacturing (Star Trek food replicator) a process
where a machine builds up products atom by atom[92] and areas such as the body enhancements ofhumans which will impact ability expectations ofhumans linked to occupation and with that theeducation of humans [93].

7. Conclusion

Ethics is discussed in relation to innovation forsome time. Innovation plays an important role inoccupational therapy and innovation science.
However,theoccupational
therapyandoccupational science literature around innovation
did not engage with ethics in a substantial mattersuch as employing ethical theories, ethics principles
and ethical reasoning. More concrete engagementwith ethics is needed in occupational science andoccupational therapy in order to clarify what isdeemed ethical and what ethical issues might arise
in terms of innovation in the occupational therapy
field.

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93. Wolbring, G.; Yumakulov, S. Education through an
ability studies lens. Zeitschrift für Inklusion 2015, 10,
no page number.

Call for Papers: The Eleventh Kumamoto
University
International
Bioethics
Roundtable: Philosophy and practice of
bioethics across and between cultures,
18-19 November 2017, Kumamoto University,
Japan;
Contact:
KimikoTashima,
Email:
ktashima@kumamoto-u.ac.jp

59

On Being the Hippocratic Doctor:
Views of House officers in a
Nigerian Teaching Hospital- Onochie Okoye
Department of Ophthalmology, College of Medicine,
University of Nigeria, PMB 01129, Enugu, Nigeria
Email: onochie.okoye@unn.edu.ng- Ferdinand Maduka-Okafor
Department of ophthalmology, College of Medicine,
University of Nigeria- Anthonia Udeaja
Department of ophthalmology, Anambra State
University Teaching Hospital, Awka, AnambraState,
Nigeria- Abali I Chuku
Federal Medical Center, Umuahia, Nigeria

Abstract

Medical students in many countries take a medical
oath on graduation from medical school. Given that
there is little or no formal medical ethics educationin many Nigerian medical schools, the current
relevance of swearing to these medical oaths isbeing questioned. This study determined mainly
the views of pre-registration house officers(PRHOs) on the relevance of the Hippocratic-based
medical oaths and some selected issues related tothe ideals espoused therein. Using selfadministered questionnaires, a cross-sectional
survey of PRHOs was conducted in 2013 as a preorientation workshop activity in Nigeria.
Respondents were simply required to indicate if
they agreed/disagreed with 29 perception
statements related to the medical oaths and theirideals. Simple descriptive analysis was done using
the Statistical Package for Social Sciences version
19. The sample included 63 males and 41 females,
who had all sworn to the Physician’s Oath at their 9
respective medical schools. Though only two
respondents (1.9%) were confident about reciting
the Physician’s oath/any medical oath frommemory or recalling all the specific details
contained in it, the majority of them agreed with all
the traditional ideals espoused in the Hippocraticbased oaths, including the prohibitions on abortion,
euthanasia/physician-assisted suicide and sexual
misconduct. Contemporary issues like doctors’
strike actions, job security/self-preservation issues
and demand for payment of hospital fees before
service were shown to be contentious issues forwhich there was no explicit guidance from the
medical oaths. For these oaths to gain greater
relevance and priority among these doctors, theyshould be recited within the context of a reformed

60

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

undergraduate medical educational system with an
integrated medical ethics curriculum and afunctional health care system that is responsive andsensitive to societal needs and changes.

1. Introduction

Although oath taking is common in many societies,
its importance and impact varies among the major
professions, with the taking of the Hippocratic oathbeing widely invoked in the popular medical
culture as being contributory to conveying a
direction to medical practice and the medical
profession [1]. Most medical graduates will take a
medical oath to inspire them to take their proper
place in the comradeship of physicians and remindthem of their obligations to their patients, society
and their profession [2]. The recitation of such anoath is a laudable tradition that provides a link to
the history of medicine, affirms the solemnity of a
medical career, and acknowledges the public’s trustin doctors[3].
Included in the classical Hippocratic Oath arecontent domains espousing loyalty to colleagues,
profession and teachers, protecting patient
confidentiality, avoiding sexual misconduct, nonexploitation of patients, prohibition of abortion,prohibition of physician assisted suicide or
euthanasia, putting the patient’s welfare first,
acting with beneficence or non-maleficence,
professional integrity, acknowledgement of limitsof competence and willingness to refer tospecialized colleagues, furthering a just society,respecting the law and/or laws of humanity,
avoiding bias or prejudice, and commitment topeace[4]. With growing attention and interest in
medical oaths, the medical profession has
witnessed the creation and use of both Hippocraticand non-Hippocratic based oaths, with some of thelatter often times being authored by medical
students and/or clinical faculty and projectingsome of the ideals in the original Hippocratic oath[4]. One such variant, generally considered as themodern version of the Hippocratic oath and widelyused, is the World Medical Association (WMA)
Declaration of Geneva’s Physicians Oath [5].
Embodied in this declaration are the guidelines forbehavioral interaction between practitioners andtheir patients, practitioners and their teachers,
practitioners and their colleagues, as well aspractitioners and humanity/society as represented
by law and the government.
In Nigeria, all fresh medical graduates onformal induction into the medical profession are
required to publicly declare their readiness to obey
the professional rules and regulations (Code of
Medical Ethics in Nigeria) of the Medical and Dental

Council Of Nigeria (MDCN-the regulatory body for
medical and dental practice) and all other laws forthe control of the medical profession, as well as
subscribe to the Physicians’ Oath [6], these being
the core of medical ethics and professionalism inthe country. All the newly inducted doctors areconsequently given personal copies of the Code of
Medical Ethics booklet together with theirprofessional temporary registration licenses but it
is doubtful if this actually generates acommensurate level of interest in medical ethics.
Incidentally, there is no documented formal
undergraduate medical ethics and professionalism
education program that is actively being
implemented in most Nigerian medical schools.
Undergraduate medical education remains largely
focused on traditional clinical and basic medical
science components, leaving students to develop
moral attitudes passively through observation andintuition [7], a situation worthy of note given thatpaternalism is still very much alive and well inmany of the routine doctor-patient interactions in
the Nigerian society. Even when ethics instructions
had been given, anecdotal evidence points to thesebeing very inconsistent and the specific teaching onthese medical oaths being highly variable.
Against this backdrop, the current relevance ofswearing to these medical oaths is being
questioned, particularly when these young doctors
are compelled into participating in these oathtaking ceremonies. There is paucity of evidence inour settings on how much of these declarations are
retained, recalled and applied by these young
doctors in the course of their duties. As apreliminary step to developing a curriculum forundergraduate medical ethics in Nigeria, our study
determined the views of pre-registration houseofficers (PRHOs) on the relevance of the medicaloaths and some selected issues explicitly or
implicitly related to the ideals espoused in these
Hippocratic-based medical oaths.

2. Methods

A descriptive cross-sectional survey of preregistration house officers(PRHOs) was conducted
in 2013 as a pre-workshop activity for theorientation workshop on the ‘’Doctor-Patient
Relationship” organized for the fresh intake of
PRHOs for a teaching hospital in Nigeria. Selfadministered 37-item anonymous questionnaires
were distributed among all the eligible and willing
workshop participants and, the completed ones
were consequently retrieved on-the-spot by the
research assistants after 30 minutes.

Eubios Journal of Asian and International Bioethics 27 (March 2017)
Table 1: The views of 104 PRHOs on statements
regarding medical oaths
Perception statement

Hippocratic oath or
the physician’s oath
are still relevant tomodern medicine
The current medicaloaths should be
revised in the faceof emerging &evolving trends inmedicine & society

Agree
(%)
75(72.1)

68 (65.4)

Disagree(%)
14(13.5)

21 (20.2)

Not sure(%)
15(14.4)

15 (14.4)

Medical schools
should abrogate themedical oaths

17 (16.4)

64 (61.5)

23 (22.1)

Graduating doctors
should write theirpersonal oaths

14 (13.5)

79 (75.9)

11 (10.6)

52 (50)41 (39.4)

11 (10.6)

Oath taking
ceremonies
automatically commit
doctors
to ethical conduct &practice
A pan-professional
oath for all healthworkers isdesirable, sincemodern health care ismultidisciplinary

68 (65.4)

22 (21.1)

61

Table 2: The views of 104 Pre-registration houseofficers on statements on certain ideals guiding
professional practice
Perception statement

Agree
(%)

Disagree (%)

Not sure(%)

A doctor’s life should beentirely consecrated to theservice of humanity devoid of
any other considerations

80(76.9)

11(10.6)

13 (12.5)

Medicine must be practiced
always with respect,
conscience, dignity, integrity &honour102(98.1)Nil

2 (1.9)Doctors should only undertakeinterventions within theirprofessional competence

96(92.3)

6 (5.8)2 (1.9)Job security and selfpreservation should be of
secondary concern to doctors

39(37.5)

37(35.6)

28 (26.9)

Doctors should never embark
on industrial strike actions

37(35.6)

31(29.8)

36 (34.6)

Doctors should always abstain
from any mischief or
corruption

103
(99)

Nil

1 (1)

14 (13.5)

Respondents were simply required to indicate
if they agreed/disagreed with 29 perception
statements related to the relevance of the medicaloaths and the ideals espoused in these Hippocraticbased medical oaths (specifically the Physician’s
declaration and the Hippocratic Oath). The
responses to these statements were initially basedon a 5 point Likert scale: 1=strongly disagree,
2=disagree, 3=not sure, 4=agree and 5=strongly
agree, and subsequently grouped into 3 categories:
1 and 2=disagree, 3=not sure, and 4 & 5=agree.
Frequencies, proportions and percentages weregenerated on these responses, using the Statistical
Package for Social Sciences SPSS Version 19.
Questionnaires with incomplete entries were
excluded from analysis. Approval for the study was
obtained from the Health Research Ethics
Committee of a university Teaching Hospital in
Nigeria.

3. Results
The sample included 63 males and 41 females, witha response rate of 94.6% (104/110). All the
respondents had trained in 9 different medical
schools within Nigeria. The mean (SD) age was 26.2
(2.7) years. All the respondents identified
Christianity as their religion. All had participated ina mandatory medical oath-taking ceremony, on
graduation from their respective medical schools.
Though all stated that they were aware of theoriginal Hippocratic Oath and/or the Physician’sOath, only two respondents (1.9%) were confident
about reciting the Physician’s Oath/any medical
oath from memory or recalling all the specificdetails contained in it. Tables 1 to 4 show the viewsof the 104 respondents on the 29 perception
statements presented in the questionnaire.

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

62

Table 3: The views of 104 pre-registration houseofficers on statements on ideals related to the doctorpatient relationship
Perception statement

Agree
(%)

Disa
gree
(%)

Not
sure
(%)

A doctor must act in the bestinterests of the patient always

95(91.3)

4
(3.9)

5
(4.8)

A doctor must act to avoid
causing any form of harm to thepatient always

93(89.4)

4
(3.9)

7
(6.7)

A doctor should not use his
medical knowledge to assist in
the termination of a patient’slife(Euthanasia etc)

87(83.6)

413(3.9) (12.5)

A doctor should not act toterminate a viable pregnancy

78 (75)818(7.7) (17.3)

A doctor must hold all
information about his patients in
confidentiality always, even after
death

87
(83.6)

6
11(5.8) (10.6)

A doctor should not insist on
payment before attending to any
patient

38(36.5)

3036(29) (34.6)

A doctor should not issue acertificate of medical fitness
without conducting the necessary
examinations

91 (87)8(7.7)

A doctor should not issue a sickleave certificate to any
undeserving patient, irrespectiveof the situation

89
(86)

A doctor should not prescribe
treatment over the telephone oremail without first seeing andexamining the patient

77 (74)

17
(16)

10
(9.6)

A doctor should avoid all
intimate relationships with one’s
patients

98 (94)

2
(1.9)

4
(3.9)

5
(4.8)

6 9(8.6)(5.8)

4. Discussion
With significant shifts in the traditional moral
grounds of the society against the background of
scientific/technological advances, the medical
profession is increasingly being required to face
hard choices in patient care and to re-examine its
own role in health care and the nature of its values[8]. The medical oaths, be it the modernized
Hippocratic oath, Declaration of Geneva, Prayer ofMaimonides, oath of Louis Lasagna or othervariants [9], are thus being re-appraised afresh forboth moral and professional guidance. The main
intention of a medical oath seems to be to declarethe core values of the medical profession and tostrengthen the necessary resolve in doctors to
exemplify professional integrity [8]. However, withincreasing consideration of religious andgovernmental issues which impinge on professional
behavior, concerns over the moral nature of
medical education and practice are being brought
to prominence by students, practitioners, andfaculty. Oaths are deontological in that they bindthe oath-taker to certain kinds of duties andobligations, and partaking in such is regarded as asymbolic, integral and shared aspect ofprofessionalization [4]. By providing the oathtaking young doctor with a set of general ethicalprecepts and prohibitions, he is then expected toapply such to situations arising in daily medical
practice and interactions.
Table 4: The views of the 104 PRHOs on perception
statements regarding relationship with teachers,colleagues & students/trainees.
Perception statement

Agree
(%)

Disa
gree(
%)

Not
sure
(%)

A doctor should show all his teachers
unconditional respect & gratitude,
which is their due

91
(88)

6
7
(5.8) (6.7)

A doctor should help all his teachers in
professional matters, if & whenrequired

89
(85)

4
11
(3.8) (10.
6)

A doctor should help all his teachers inother matters, if & when required.

72
(69)

15
(14)

A doctor should relate with all otherdoctors as family, & not merely as
colleagues

77
(74)

9
18
(8.7) (17)A doctor should impart medical
knowledge only to those students,
trainees & colleagues he considers
responsible and serious

19
(18)

65
(63)

A doctor should impart medical
knowledge to any student, trainee orcolleague wishing to learn

97
(93)

3
4
(2.9) (3.8)

A doctor should avoid intimate
relationships with one’s students or
trainees.

91
(88)

4
9
(3.8) (8.7)

17
(16)

20
(19)

Eubios Journal of Asian and International Bioethics 27 (March 2017)
Oath–taking among professionals is aubiquitous practice and even among Africans, theconcept is enshrined in the idea that it is usually aceremony of great solemnity and a publicattestation of the veracity and sincerity of theswearer’s words and actions. Yet, as the use of themodern medical oaths has burgeoned, theircontents have veered away in so many ways fromthe original oath’s basic tenets. Many contemporary
oaths seem diluted and the lack of enforceable
sanctions for defaulters seemingly render them
toothless in their impact. A growing number ofpractitioners had come to feel that the Hippocratic
Oath is inadequate to address the realities of a
medical world that has witnessed huge scientific,
economic, political and social changes; and that the
principles enshrined in the oath do not constitute ashared core of moral values for adherents of otherreligions, considering its pagan origins. With allthese in mind, some doctors see oath-taking as little
more than a pro-forma nostalgic ritual with little
value beyond that of upholding tradition, being anear-meaningless formality devoid of any influenceon how medicine is truly practiced in the real world[10].
Our study demonstrated that all the medical
schools attended by the respondents administered
the Physician’s Oath to their graduates, in line withthe requirements of the Medical and Dental Councilof Nigeria (MDCN). Though the Physician’s Oath is amodernized form of the classical Hippocratic Oath,it differs mainly from the original version in not
making reference to God or any deity, sexual
misconduct,abortion,
euthanasia/physicianassisted suicide and possibility of consequences for
failure to live up to the stated ideals. This use of
only the Physician’s Oath in these oath-taking
ceremonies is very much unlike the situation insome other parts of the world, where various formsof oaths were used, with some versions being
authored by the students and some schools evenoffering their students a menu of oaths to pick fromfor use in graduation ceremonies and otherrelevant events [4].
Studies have shown that over the last couple ofdecades the prevalence of oath taking in U.S
medical schools had grown remarkably from only
28% in 1928 to involve all allopathic schools andosteopathic schools by 1993 [11], with only 1.6% of
100 allopathic schools using the Declaration of
Geneva and 21.3% using a modified Declaration of
Genevain 1993 [4]. On another note, acontemporary medical ritual called the white coatceremony is now being practiced at more than 100
American medical schools, in which first year
medical students publicly vow to abide by the63

medical oaths occasionally authored by thestudents and/or faculty [12].
The degree of importance which thesegraduating students attach to these medical oaths
had also been called to question at various times. In
our study, virtually none of the PRHOs was
confident about reciting the contents of any medical
oath by memory or recalling all the specific details,
a situation corroborated in other studies where it
was stated that the contents of the medical oathsworn to were often soon forgotten [13,14]. On thecontrary, those students who had formally studied
the medical oath were shown to have a better recallof its principles [14]. In line with that finding, it wassuggested that, at a minimum, the last hours of
medical school education be devoted to a formal
study of the Hippocratic Oath [14]. Thus, the role ofmedical oaths in the ethical education ofundergraduate medical students will need to be reassessed in our medical schools, if these young
doctors are to stop regarding these oath-taking
exercises as mere ritualistic recitations. The needfor formal instructions is buttressed further by theassertions of majority of our respondents that the
medical oaths are still relevant to modern medicine
and as such, should not be abrogated.
Further analysis of their views on the medicaloaths (Table I) shows a preference for a revision of
the medical oath to align with evolving trends inmedicine and society, without necessarily expecting
graduating doctors to write their personal orpreferred oaths. The use of non-standard oaths may
make oaths and oath taking more relevant anduseful as means of promoting professionalism but it
may also lead to fragmentation and confusion about
the ethical values of the medical profession, thereby
diluting the value of a professionally binding oath.
At our level of National development, offering
students a menu of oaths to select from as practiced
in the western world may further worsen thesituation as mixed messages will be sent out tothese students from time to time, erroneously
conveying the impression that medical oaths are
flexible documents which can be framed in any
form to suit the oath-taker [4]. Such a situation may
not augur well for the ethical and professional
development of these young doctors, given thatthey had little or no formal medical ethics teachingas undergraduates. With respect to possible
revisions required on the currently used
Physician’s oath and the oath-taking ceremony,further qualitative studies are imperative, involving
the MDCN, medical educators, policy makers,
administrators, medical practitioners, patients aswell as the students. The development and use of amore socio-culturally sensitive and relevant oath64

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

may also enhance the importance and relevance of
these medical oaths to these graduating doctors.
Also, worthy of note is the view held by the
majority of respondents about the desirability of apan-professional code. If such were to promoted, it
could engender a positive degree of moral cohesion
between all caring professions, across institutionalboundaries, influencing perhaps even theorganization of health care [8]. The hope is that asingle oath for all health care professions could heal
split loyalties and ameliorate existing moral
tensions in health care [8]. However, this may only
be worthy consideration with the active
cooperation of all the other stakeholders in thehealth care sector, and may not be currently
feasible in Nigeria considering the prevailing levelof inter-professional disharmony in the healthsector.
The Hippocratic Oath’s timelessness as atouchstone of medical care rests in an emphasis on
the values of an ‘’ideal physician’’ [15], even though
one may not know to what extent these values are
actually taught in the medical schools. There is noreference in it or other variants to the facts andskills that a doctor must know, only to the
behaviors expected in the practice of medicine [15].
Although there is paucity of data on the impact of
medical oaths upon oath-takers’ behaviors, a study
in Israel showed that the medical students doubted
the oath’s influence [16]. Analysis of the views of
the PRHOs on the perception statements (Tables 2to 4) in our study indicate a reasonable level ofagreeability with the ideals espoused in the medicaloaths. Though oaths may not compel behavior, they
may serve to sensitize the oath-taker to the
ethically or professionally appropriate choices
inherent in any interaction. There may be adiscrepancy between the respondents’ standpoints
on the perception statements and their actual
behavior in their everyday practice. Though thequestionnaires were self–administered andanonymous, it is still possible that the frequency ofagreement with those statements in support of theideals espoused in these oaths might be overestimated due to social desirability effect.
Given that the Physician’s Oath does not makeany explicit references to sexual misconduct,abortion and euthanasia unlike the classicalHippocratic Oath, their responses on the related
perception statements are apparently indicative of
these doctors’ belief that their first responsibility is
to care for their patients, acting as a fiduciary forthe patient and keeping with the traditional
Hippocratic moral obligation of providing net
medical benefit to the patient without causing harmin any form. In addition, the underlying influencesof their Christian and socio-cultural beliefs

regarding the sanctity of life and the fact thatabortion and euthanasia are illegal in Nigeria are
obviously contributory to the views expressed.
Regarding sexual relationships between doctors
and patients or between doctors and their students,
these issues are still subjects of ethical and legal
analysis in many places and their inclusion in themodern medical oaths is still being debated globally[17].
One criticism some people have against manyof the medical oaths is their perceived failure tokeep up with contemporary issues in society andthe medical profession. Legally, however, medical
doctors in Nigeria are not held strictly accountable
as fiduciaries as they may also have obligations andallegiance to other parties such as the Nigerian
Medical Association and the National Association of
Resident Doctors. In a society grappling withchanges characterized by unionization of the
medical profession, institutionalization anddepersonalization of health care, incessantindustrial strike actions and competition within thehealth sector, advertising/commercialization ofpractice, and specialization in medicine, it is
becoming more imperative that graduating doctors
be provided with the requisite knowledge and skills
for navigating through this emerging and evolving
landscape of ethical and professional challenges.
The pattern of responses (evenly distributed
across the three categories of responses) observedin relation to 3 perception statements on doctors’
involvement in strike actions, job security/selfpreservation issues (Table 2) and demand for
payment of hospital fees before service(Table 3)shows a gap in knowledge and some level ofconflict among the significant proportions of thestudy sample with respect to identifying the
expected behavior in those circumstances asprescribed by the tenets of the medical oaths or thecode of medical ethics, given that these oaths do notalso make any explicit reference to these threeissues.
In Nigeria, as in so many other developing
countries, strike actions had been carried out inprotest over a wide array of reasons including poor
remuneration, staff welfare/job security issues,
health infrastructural deficiencies, and poor qualityof health services. There is still no single bestanswer against or in favour of doctors’ strikeactions [18]. Utilitarians may justify such actions on
the basis of potential long-term benefits to thedoctor, patient and the health care delivery
systems. Others would, nevertheless, argue that
under the Hippocratic-based oaths, care of thepatient is mainly a social contractual obligation forthe doctors and should have primacy over otherconsiderations [18].

Eubios Journal of Asian and International Bioethics 27 (March 2017)
Regarding payment for services, some may
argue that the historical rule is that a doctor is notbound to accept a patient regardless of the severityof the condition, but that it becomes ethicallyindefensible to do such once the contractual doctorpatient relationship is established. The demand for
cash deposits in Nigerian hospitals before a patientis treated has become a dangerous trend in thehealth care sector [19]. The propriety or otherwiseof this practice is still debatable as there is no clear
legal reference point in Nigeria to compel a medical
practitioner to treat a patient who is unable to pay,
unlike in some jurisdictions like America which
require a practitioner to accept an indigent patient
for treatment, this being predicated on theprinciple of preserving life at whatever costs [19].
On a related note, medical students in Nigeria wereshown in another study to have identified issues
related to payment of medical bills as among theleading ethical challenges confronting medical
doctors in Nigeria [7]. There is no doubt that thisissue along with other debatable issues arechanging the entire construction of medical
practice and education in the country.
As a curricular event required for the
professional development of these fresh medical
graduates, the tradition of taking of medical oaths
at formal ceremonies should be sustained by
medical schools. Although all the traditional tenets
and ideals espoused in these oaths continue toresonate with these junior doctors, there is a needto review the contents with a view of addressing
the emerging and evolving realities of the medical
environment in Nigeria, an environment that has
witnessed significant social, economic, cultural andpolitical changes. For these oaths to gain greater
relevance and priority among these doctors, theyshould be recited within the context of a reformed,
robust undergraduate medical educational systemwith an integrated medical ethics curriculum and afunctional health care system that is responsive andsensitive to societal needs and changes.

References
1) Jotterand F. The Hippocratic Oath and contemporary
Medicine: Dialectic between past ideals and present
reality. Journal of Medicine and Philosophy 2005;30:107-128
2) Meffert JJ. ”I Swear!’’ Physician oaths and their current
relevance. Clinics in Dermatology 2009; 27:411-415.
doi:10.1016/j. clin. dermatol. 2009.02.016.
3) Newman A, Park IR. An oath for entering medical
students. Academic Medicine 1994 Mar;69(3):214.
4) Kao AC, Parsi KP. Content analyses of oaths
administered at U.S. medical schools in 2000. Acad Med
2004;79(9):882-887.
5) The World Medical Association. Declaration of
Geneva. Geneva,Switzerland. Adopted September 194865

andamended
1968,
1983,
1994.
www.wma.net/en/30publications/10policies/g1/WM
A_DECLARATION-OF-GENEVA_A4_EN.pdf(accessed
December 20,2016).
6) Abegunde B. Legal implications of ethical breaches inmedical practice: Nigeria a case study. Asian J
Humanities and Social Sciences 2013 Nov; 1(3):69-87.
7) Ogundiran TO. Adebamowo CA. Medical Ethics
Education: A survey of opinion of medical students in a
Nigerian university. J Acad Ethics.2010;8(2):85-93.
8) Hurwitz B, Richardson R. Swearing to care: theresurgence in medical oaths. BMJ 1997;315:16711674.
9) Jonsen A. A short history of medical ethics. Oxford:
Oxford university Press, 2000:4
10) Tyson P. The Hippocratic Oath today. NOVA.
www.pbs.org/wgbh/nova/body/hippocratic-oathtoday.html. Accessed December 23,2016.
11) Orr RD, Pang N, Pellegrino ED ,Siegler M. Use of the
Hippocratic Oath :a review of twentieth century
practice and a content analysis of oaths administeredin medical schools in the U.S. and Canada in 1993. J
Clin Ethics 1997; 8:377-388.
12) Huber SJ. The White coat ceremony: a contemporary
medical ritual. J Med ethics 2003;29:364-366
doi:10.1136/jme. 29.6.364.
13) Loudon I. The Hippocratic Oath. BMJ 1994; 309:414.
14) Moffic HS, Bayer T, Coverdale J. The Hippocratic Oathand medical students. Acad Med 1990 Feb;65(2):100101.
15) Stern DT. Practicing what we preach? An analysis of
the curriculum of values in medical education. Am J
Med 1998; 104: 569-575.
16) Yakir A, Glick SM. Medical students’ attitudes to the
Physician’s Oath. Med Educ 1998; 32:135.
17) Perez SG, Gelpi RJ, Rancich AM. Doctor-patient sexual
relationships in medical oaths. J Med Ethics
2006;32:702-705 doi:10.1136/jme.2005.014910
18) Abbasi I N. Protest of doctors: a basic human right oran ethical dilemma. BMC Med Ethics 2014,15:24.
http://www.biomedcentral.com/1472-6939/15/24
19) Obidimma EOC, Obidimma AE. Legal and ethicalissues in the demand for payment before treatment in
Nigerian hospitals .Journal of law, policy andglobalization 2015;38:176-181.

66

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

Unethical Clinical Trials in India: A
Selective preliminary overview- Ankita Chakravarty
West Bengal National University of Juridical
Sciences, No.12, LB Block,- Ambedkar Bhavan
Sector III, Salt Lake City, Kolkata, West Bengal
700098, India

Abstract
This paper attempts to study the phenomena ofclinical trials in India with a specific focus on the
conduct of unethical trials. There has been awidespread chronicling of the rise of the great
pharmaceutical power, the triumphs leading to
improvements in life expectancy along withtreatments and cures for numerous diseases. But
there has also been the equally fascinating tale of
the appalling usage of power in the form of
coercion and deceit, with human beings exploitedand subjugated to horrific forms of torture for theadvancement of scientific knowledge and financial
gains.

1. Introduction

There are legal and ethical provisions relating to
the clinical trials sector and these provisions havebeen formulated both at the international andnational levels and one of their major aims is toprovide protection to the participants of clinical
trials. However, despite the existence of a numberof ethical guidelines as well as the legal stipulations,
there have been numerous instances of clinical
trials being conducted unethically and illegally in
India. While such trials have been reported fromother parts of the world as well, there have beenquite a few Indian cases recently which continue tobe in focus- thereby providing the basis for thisresearch work.
India has been hailed as an emerging clinical
trial location over the last decade or so and thedifferent advantages it offers have been repeatedly
highlighted (Yee 2012). Pharmaceutical companies
are the major sponsors of clinical trials and as more
and more of these companies venture into drug
development and clinical trials, there is a need tohave access to a large pool of participants for thetrials. Along with the population advantages andthe availability of lower cost of labour and expertiseavailable in India, the facilities promised by theGovernment have also played an important role insetting up India as an attractive location. However,
the reports of trials being repeatedly carried out
unethically and illegally have raised certain

questions about the functioning of the clinical trials
sector in India.
This study seeks to investigate the clinical
trials sector in India as, over the last few years, thequestion of clinical trials in India has been acontentious one. This is largely because a numberof trials were found to have been conducted on
Indian patients without following the necessary
legal and ethical principles (recently, for instance,
the HPV Vaccine trial, Indore Public Hospital andBhopal Memorial Hospital trials). It is this area
within the clinical trials sector which forms thefocus of this work- however, the scope of this paper
is only limited to an overview of some of the earlier
reports of unethical trials in India. For this purpose,the publication of the ICMR Ethical Guidelines has
been taken as the integral development, and hence,
only trials which were reported prior to thedevelopment of the guidelines have been includedin this short review.

2. The ethical questions:clinical trials in India

unethical

In order to gain an insight into the clinical trials
sector in India, we need to try and understand thecontext in which it was established and thesubsequent path of its development. This
necessitates identifying the historical cases ofunethical trials in India along with documenting therecent cases.
The cervical dysplasia trial was perhaps thefirst well documented case of trials being
conducted in India. In 1970s and 1980s researchersat the Institute for Cytology and Preventive
Oncology which is an institute under the IndianCouncil of Medical Research (ICMR) in New Delhi,
carried out a study on women patients who
presented with different stages of cervical dysplasia
or what were suspected to be precancerous lesionsof the cervix. The women were not informed thatthey were participating in a trial, and hence, noneof them were asked for consent. Nonetheless, it
should be noted that the researchers said that they
took verbal consent from the women who were
illiterate. They also argued that the study was
justified in that there was ‘no conclusive evidence’that all severe dysplasias develop into cancer.
However, while the study was underway, a major
North American medical journal published thefindings of a longitudinal study of cervical cancer.
The study concluded that cervical dysplasia
was indeed a precursor for cervical cancer, andthus that all forms of dysplasia were to be treated.
However, despite these new findings, the Indian
researchers continued with the study. The subject
participants were left untreated to see how manyEubios Journal of Asian and International Bioethics 27 (March 2017)
lesions progressed to cancer and how many
regressed. By the end of the study seventy-one
women had developed malignancies and lesions innine of them had progressed to invasive cancer.
Sixty-two women were treated only after they
developed localised cancer. It was largely due to thecontroversy that erupted after the study was
highlighted in the 1990s, that the ICMR Ethical
Guidelines for Biomedical research in Human wasformulated in 2000 (Srinivasan, 2005).
Although India adopted Schedule Y and
Schedule XA of the Drugs and Cosmetics Rules 1945
which relates to clinical trials in 1988, the study
highlights the ethical issues that can emerge inclinical trials, and therefore establishes why suchtrials need to be closely regulated. Further, theprinciples enshrined in the Helsinki Guidelines
were not adhered to. While the investigators
asserted that they had acquired verbal consent,
there was no evidence that the women had been
informed about their potential participation in aclinical research study. Further, despite the factthat the research published in the journal clearly
established that all forms of dysplasia warranted
treatment, the Indian investigators continued withthe study. This is clearly not in keeping with Article
7 of the Helsinki Guidelines (1964) which
establishes that ‘physicians should abstain fromengaging in research projects involving humansubjects unless they are satisfied that the hazards
involved are believed to be predictable. Physicians
should cease any investigation if the hazards arefound to outweigh the potential benefits’. Further, it
had been clearly stated in the introduction to theguidelines that the mission of the physician was tosafeguard the health of the people.
It also needs to be clarified that in thepresentation of this case as well as the othersubsequent cases, the term ‘subject participant (s)’is being used. What is being referred to is, theprocess of the constitution of the trial participant asa ‘subject participant’ rather than merely avolunteer participant. This is especially true in caseof unethical trials where the patients may not beaware of or fully comprehend their status as
experimental sites. However, the intrinsic unequal
power relations between the trial organizer and theparticipant also constitute her/him as a subject
participant even if she/he is aware of the trial. The
vulnerability and defenselessness of their position
is more markedly revealed since it is their own
resource of life which is leased out as resource
matter for trial activities which are carried out toostensibly improve life existence and yet, may
paradoxically lead to diminishing of their own life
existence.

67

The second case being presented here is fromthe 1990s. A huge multi-country unauthorized trial
was carried out on thousands of illiterate Indianand Bangladeshi women wherein the anti- malarial
compound mepacrine was used in pellet form as ameans of female sterilization. Once inserted into
the women’s uterine cavity, it caused inflammationand scar tissue formation which closed off the
fallopian tubes permanently.15 While the trials had
been stopped in the West, the compound had been
directly distributed to medical practitioners inIndia. More than 30,000 women in India had beensterilised using this illegal and untested method, atleast 10,000 in West Bengal alone. This trial
demonstrates the differing ethical standards
applied in different country settings. In what was
clearly an illegal move, although the trials had been
stopped in the west, the intervention was directly
distributed to medical practitioners instead ofbeing properly approved for testing. The Supreme
Court banned the use and sale of this drug but it
continued to be available in rural Bengal for up to
five years after that (Dasgupta, 2005).
The M4N AND G4N trial is another importantcase in the account of India’s clinical trial history. In
1999, 27 16 people with oral cancer were under
treatment at the government-run Regional Cancer
Centre in Thiruvananthapuram. Although there
were established protocols of treatment including
surgery, chemotherapy and radiation options, thepatients were given first-in-human experimental
drugs, tetra-O-methyl nor-dihydro-guaiaretic acid
(M4N) or tetraglycinyl nor-dihydro-guaiaretic acid
(G4N). The aim was to determine whether thesechemicals could arrest the growth of oral cancer.
Although the subject participants were made tosign consent forms, they were not informed thatthey were participating in a research study or that
there were other approved means of treatment for
their condition. While approval for the anti-cancer
15Mepacrine is the name of the compound, but it was
better known by its commercial name Quinacrine.
Although its use in sterilization has passed throughseveral small trials, there has been no overall dismissalof its link to cancers and ectopic pregnancy and hence,
WHO convened a technical consultation which decided
that Quinacrine should not be used for sterilization
purposes in women, either in research or therapeutic
settings. (WHO Technical Consultation, 2009)16 While the questions on the ethical conduct of the trial
are numerous, there also appears to be some confusionon the total number of trial participants. The RCC had
initially acknowledged 27 patients but later released
data on only 23 of them. Subsequently, only 18 cases
were taken into account.

68

Eubios Journal of Asian and International Bioethics 27 (March 2017)drug trial was taken from the Indian drug regulator
only after the trial was underway (Srinivasan,
2005), ethical clearance from the collaboratingorganization- John Hopkins University had also notbeen provided.
The trial was only thrust into the media
spotlight after a radiotherapist from the centre
raised serious questions on the conduct of the trial.
While there was an enquiry established in India as
well as in the US, only ‘procedural lapses’ were
found to have occurred. However, it must be notedthat the University barred the principal investigatorfrom conducting any further research on thechemical entities and also provided that any further
human clinical research to be carried out by theinvestigator would have to be supervised bysomeone from the University who had experiencein dealing with human trials (Frontline, Vol.22 Dec.
2005). Subsequently, animal testing was done onthese chemicals before the launch of Phase 1 trials
on humans in USA. Moreover, the volunteers in the
US trial were patients who did not have any
therapy option available to them. This was not thecase with the Indian subject participants. Thisparticular trial also serves to highlight the
reprehensible process in which trials are organizedin India. Firstly, the subject participants were notinformed that they were participating in a clinical
trial, and thereby receiving experimental therapy as
opposed to approved therapy, thereby effectively
amounting to denying them treatment.
Moreover, the trial was initiated before
permission was sought, which was illegal as per
Section 1.2 of Schedule Y of the Drugs andCosmetics Act, 1945 (GSR 944 (E) 1988). Further,
the ethical committee clearance of the collaborating
body should also have been obtained as no suchclearance had been acquired. It may be pertinent topoint out that one of the possible reasons for the
ethical clearance not being sought from John
Hopkins University, might have been that it would
have been unlikely that permission would havebeen granted because of the serious ethicalquestion on the study itself. Hence, the question
cannot be looked at in isolation- what also needs tobe focussed upon is the undeniable role of thecontext of such a trial. This refers to the fact thatthe trial was being carried out in a third world
nation-state which has a history of poor regulatory
oversight; also the lack of ethical clearance from the
US (first world) makes it an intriguing case andraises the pertinent question of elitism and even,worryingly, racism.
These three trials are illustrative cases of thenature and extent of unethical as well as illegal
practices that are widely prevalent in the pursuit ofclinical research in India. To state clearly, all ofthese studies violated the four basic tenets of ethics
as per the ICMR Ethical Guidelines- autonomy(respect for person /participant), beneficence (actfor the benefit of person/participant), nonmaleficence (do no harm) and justice (ICMR Ethical
Guidelines). Subjects were not informed that they
were participating in clinical research and actual
informed consent was not taken. Participants were
subjected to the trials while being deliberately
deceived that they were receiving standardized
therapy as opposed to experimental interventions.
The three cases of unethical trials that were
presented- the cervical dysplasia trial, themepacrine pellet trial and the G4N & M4N trials
were all conducted before the ICMR Ethical
Guidelines for Biomedical research in Human
Subjects was presented in 2000, although the'Policy Statement on Ethical Considerations
involved in Research on Human Subjects' had infact, been published in 1980. The ICMR Ethical
Guidelines for Biomedical research in Human were
published first in 2000 while the CDSCO prepared
the Indian Good Clinical Practice (GCP) guidelines
in 2001. It is to be expected that after the
categorical formulation of ethical and clinicalconsiderations necessary for conducting clinicalresearch in India, the situation would be somewhat
different.
However, reports over the last few years havenot been positive and instead brought to lightfurther examples of unethical conduct of clinical
trials. However, that is beyond the scope of thispaper.

3. References

Dasgupta,R. (2005)‘Quinacrine Sterilization in India:
Women’s Health and Medical Ethics Still at Risk
’http://www.global-sisterhoodnetwork.org/content/view/237/59/
Krishnakumar, R. ‘Trial and Errors’ Frontline, Volume
22- Issue
25, Dec. 03- 16, 2005
http://www.hindu.com/thehindu/thscrip/print.pl?file=20051216005102200.htm&date=fl2225/&prd=fline&
ICMR Ethical Guidelines, 2006
Helsinki Guidelines, WMA, 1964
Srinivasan, S. (2005) ‘Some Questionable trials’
http://infochangeindia.org/publichealth/features/some-questionable-drug-trials.html
WHOTechnical
Consultation(2009)
http://whqlibdoc.who.int/hq/2009/WHO_RHR_09.21_
eng.pdf
Yee, A. (2012) ‘Regulation failing to keep up with India’s
trial boom’. The Lancet, Volume 379, Issue 9814, Pages
397 – 398.

Eubios Journal of Asian and International Bioethics 27 (March 2017)69

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For forthcoming conferences see: www.eubios.info or www.ausn.info
Call for Papers: The Eleventh Kumamoto University International
Bioethics Roundtable: Philosophy and practice of bioethics across and between
cultures, 18-19 November 2017, Kumamoto University, Japan.
Contact: Kimiko Tashima, ktashima@kumamoto-u.ac.jp