Eubios Journal of Asian andInternational Bioethic
EJAIB Vol. 31 (3) March 2021
www.eubios.info

ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2021 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

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Palliative care of terminal patients: students’ learning
process at a nursing university in Japan149- Jun Kikunaga, Sayuri Sakai, Nao Seki, Michio Miyasaka
Legal and social perspectives on euthanasia in India 154- Deepa P
Assisted Reproduction and the Japanese Paradox
158- Silvia Croydon
Bracing for the new normal or post-normal? Challenges
and aspirations of indigenous parents for educationof their children
161- R.P. Bayod, E.J.D. Forosuelo, J.P. Morante, M.C. Guerra
Global ethics and the right to universal access to
COVID-19 vaccines
169- Christopher Ryan Maboloc and Glio Joy Layos
A needs analysis of a regulatory framework forteleconsultation in Indonesia
172- Antono Suryoputro, Rani Tiyas Budiyanti, Murni
Biopower and global justice174- Christopher Ryan Maboloc
Financial constraints as grave ethical issues fordeveloping countries
177- Farah Wasaya, Sumera Zul iqar, Anila Ra iq
Teaching and learning using online educational
resources for sustainable development incollaborative learning communities
181- Suma Parahakaran
Challenges for organ recipients and elderly people insummer of 2020 during the COVID-19 pandemic184- Maria-Keiko Yasuoka
Exploring researchers’ perceptions on the consequencesof publication pressure to the research ecosystem 192- A.P. Olesen, L. Amin, Z. Mahadi & M. Ibrahim
Crisis Self-Ef icacy and Work Commitment of Public
School Teachers during COVID-19 Pandemic
198- Erick T. Baloran and Jenny T. Hernan
Ordering information, Editorial Boad and policy
204
Editorial address, and all correspondence to:Prof. Darryl Macer
Email: darryl@eubios.info

Palliative care of terminal patients:
students’ learning process at anursing university in Japan- Jun Kikunaga, M.S., R.N. (Corresponding author)
Email: miyasaka@clg.niigata-u.ac.jp- Sayuri Sakai, Ph.D., R.N.
Email: sakai@clg.niigata-u.ac.jp- Nao Seki, M.D., Ph.D.
Email: nao@clg.niigata-u.ac.jp- Michio Miyasaka, Ph.D.
School of Health Sciences, Niigata University, Japan
Email: miyasaka@clg.niigata-u.ac.jp

Abstract
Objective: This study aimed to elucidate the process of learning in
the practice of palliative care among university nursing students
and to identify the elements necessary for training healthcare
professionals working in palliative care.
Methods: Practicum records of nine nursing school students whocared for cancer patients receiving palliative care in a general ward
were included in the analysis using the qualitative synthesis (KJ)
method.
Results: The process of learning palliative care by nursing students
was characterized by a sense of inadequacy in holistic integration
and realization of a deepened relationship, which allowed them tosee the bene its of care in the patients’ calmness. This allowed
them to achieve a sense of satisfaction in mastering the nursing
process. At the same time, some students felt the importance ofeach day in terminal phase nursing and had regrets about terminal
phase nursing.
Discussion and conclusions: Two challenges were identi ied inpalliative care education: (1) The need for speci ic educational
support for students who had trouble in interacting with dying
patients and had regrets about terminal phase nursing, and (2) thelack of effective coping methods for students who experienced
internal con licts due to ethical issues surrounding terminalpatients and their families. Re lection and consultation are neededto (1) sublimate the thoughts of students who have trouble ininteracting with dying patients and regrets about terminal phasenursing into motivation for future learning, and (2) explore coping
methods to deal with ethical issues and resolve the ethicalcon licts.

sContents

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Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

Introduction
Achieving widespread practice of palliative care is achallenge in Japan as the number of patients newly
diagnosed with cancer and the number of cancer deaths in
the country is increasing1. The Basic Plan to Promote Cancer
Control Program (Phase II, enacted in 2012) urges thepromotion of palliative care from the moment of cancer
diagnosis to allow cancer patients and their families to live
high-quality lives, and has been held as a priority objective 2.
In palliative care, nurses ful ill many roles, such asalleviation of symptoms, assistance in decision-making, andhandling ethical issues. However, these skills are not easy tolearn and demand improvements in nursing programs inthese areas of education3.
In Japan, nursing education is delivered through 4-year
university programs, and they are introducing education in
palliative care as well. In 2018, the Japan Association of
Nursing Programs in Universities announced the acquisitionof skills to support terminal patients and their families as
one of the goals of university nursing education 4. Somechallenges, however, have been reported, including the factthat approximately half of the educational institutions havenot established care as an independent subject and thatstudents are being taught by teachers who are notspecialized in palliative care5. With similar inadequacies in
the current nursing education to accommodate the needs ofterminal patients in other countries6， palliative careeducation in nursing is still under development.

ffFigure 1: Learning process in palliative care

The practicum related to patients undergoing palliative
care tends to be particularly dif icult for nursing students(herein after referred to as students) too7. In the practicum,
they may be assigned to provide care for patients who are in
more severe situations than what was taught to them in
lectures and may experience patient deaths. Some students
may fear or feel distress in interacting with patients, whileothers may feel helpless because of their inability to provide
adequate care8. Meanwhile, the practicum has beenreported to help students learn communication skills toreceive terminal patients’ and their families’ views aboutlife or learn the need for ways of assistance for preserving
patient dignity9．However, virtually no studies have been
conducted to clarify the interactions of students withpalliative care patients and their families and students'
learning processes in the practicum.
Objective
This study aimed to elucidate the learning processes ofuniversity nursing students on palliative care in thepracticum and to identify the elements of practicum
necessary for training healthcare professionals working inpalliative care.
Methods
The practicum records of nine third-year nursing students
from a university in Eastern Japan who were assigned tocare for patients receiving palliative care in a general ward
in the practicum for terminal care in adult patients werereviewed. After completion of the practicum, students who

provided palliative care were requested access to theirpracticum records, and the records were collected from thestudents who provided consent. The “Activity Plan Tables”
for the days they were assigned to patients receiving
palliative care (i.e., nursing goals, nursing plans, execution
and assessment, daily schedules, self-evaluation, andinstructor records) and “Case Reports,” a document thatstudents created immediately after the practicum to record
their re lections were collected.
The above documents were used for analysis because
they would provide accurate accounts of knowledge,
awareness, and behavioral and psychological changes
experienced daily through the practicum by students. The
data were collected for the period from January 2014 toMarch 2017.
The qualitative synthesis method (KJ method) reported
by Yamaura 10 was used for the analysis. This researchmethod allows for reorganization of incoherent fragmentsof data in a coherent form and was selected as a suitable
method for integrating students' practicum records written
in mixed and fragmented manners to reconstruct theirlearning processes. The theme of analysis was “elucidationof the processes through which students acquired
knowledge and changed their perception and behavior
based on their experiences of interactions with patients
receiving palliative care in the practicum.” Individualized(per-student) analysis was initially performed, and then, theresults were synthesized for the general analysis. The
procedures adopted for the analysis were as follows:(1) Label production: Individual meanings of events orlearnings that the students experienced as found in theirrecords were summarized out on labels.
(2) Grouping: The produced labels were spread out andgrouped according to the similarities expressed by thesentences, the meanings of the groups were interpreted,and the interpreted meanings were re-written as a single
sentence that would function as the nameplate for eachconcept as viewed by the students. This series ofprocedures constituted one step, and was repeated forgrouping. The process was stopped when six or fewer labels
were left as these were deemed to be the inal labels.

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Table 1: Summary of the participantsffEubios Journal of Asian and International Bioethics 31(3) (March 2021)

151(3) Spatial placement and diagram production: The inal
labels were rearranged spatially focusing on therelationships between them to produce a diagram that
represents the overall structure. The spatial layout of thelabels in the diagram was observed to attach symbol marks
to the inal labels, which were expressed in the format of“[Matter] (Position of the label within the whole picture):
Essence (Uniqueness of the matter)”. Additionally, astoryline was created to explain the diagram.
(4) General analysis: Labels for the general analysis
included all labels that remained until two steps before theinal labels in the individual analysis. The same proceduresas steps 1) – 3) for the individual analysis were carried out
for the general analysis.
4. Ethical considerations
This study was approved by the “Ethics Committee for
Research in Human Subjects” of Niigata University(Approval No. 1684). Students received written and oral
explanations about the purpose and methods of the study,
voluntary nature of the participation, their rights towithdraw from the study at any point of time, and theanonymity and con identiality of their personal data before
they consented to participation and granted permission to
use their practicum records for the research.
Results
1. Summary of participants: Data from the records of nine
students were analyzed. Three of the students were men
and six were women (Table 1). They were assigned for thecare of patients in their 30s–80s ive of whom were men
and four were women. All cancer patients were underpalliative care for symptomatic management withcomplications and symptoms of diseases such as ileus,
pneumonia, heart failure, and kidney failure. Students
provided care for these patients for 4–14 days. Five of thepatients were hospitalized throughout the student’s
practicum period, while two were discharged, one wastransferred to another hospital, and one died. For this study,
96–386 original labels were extracted from the students’records. The differences in the numbers of the labels
depended on the amount the students wrote and theduration for which they provided care for the patient. In thisresearch, 185 original labels were used for general analysis.

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

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2. Students’ learning process inferred from general analysis:
One hundred eighty- ive original labels from the general
analysis were used to create groups up to the eighth level, at
which the inal six labels were obtained. The storyline
depicting the students’ learning process and diagram
representing the relationships between the inal labels arepresented in Fig. 1 and explained below where conceptual
matters are written in square brackets and the issues inquotation marks.
The learning process of university nursing students inthe palliative care practicum can be summarized as follows:First, students experienced their “immaturity in nursing forterminal phase patients” as [a sense of inadequacy in theability of holistic integration]. They also came to a[realization of a deepened relationship] as they were driven
by the “wish to become mutually interested in sharing thepatients’ pain and support the patients somehow.” Afterthey vacillated between these thoughts, they learned the“importance of care and consideration to help patientsspend time in calm and peace from watching the terminal
phase patients’ facial expressions” as [bene its of care (weremanifested) in the patients’ calmness]. This exercise
allowed the students to feel con ident that they were “ableto practice nursing for terminal patients with instructors’
advice” and achieve [a sense of satisfaction in mastering thenursing process]. However, at the same time, they
understood the [importance of each day in terminal phasenursing] as they reached "a new level of understanding
through their involvement with the life and death ofterminal patients.” They also felt that “they were unable toprovide adequate care for patients and experienced
con licting ethical issues” as their [regrets about terminal
phase nursing].
3．Summary of the inal labels composing the students’learning process: The inal labels composing the students’learning process are summarized below. Conseptual
matters are written in square brackets.
(1) [a sense of inadequacy in the ability of holistic
integration] Students collected necessary patient data fromthe electronic charts and from the patients themselves toassess the provision of care for terminal patients. However,the students were advised by the instructor to perform datacollection that allowed them to capture the whole picture inorder to provide the care necessary for the terminalpatients. While the students understood the importance ofadequate assessment and holistic integration from suchadvice, they also realized their inadequacies as a nurse, suchas the lack of medical knowledge and their immatureassessment skills and felt the need to study more.
(2) [realization of a deepened relationship] Students
conveyed their concern for terminal phase patients andwrote them letters. Through such forms of care, the patients
gradually began to show interest in the students. As a result,the patients opened up to the students and started tellingthem about their complex emotions and challenging
situations. The students, by watching how the patients were
ighting the disease positively, wanted to share theirsuffering and efforts and do anything to support them.

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(3) [bene its of care (were manifested) in the patients’calmness] Students saw their patients’ satis ied smiles andpeaceful expressions after they provided terminal phasepatients with hygiene care or removed restraint mittens
with their instructors and patients' families. From thepatients’ expressions, the students realized the importanceof care to help patients live in emotional peace until the last
day of their lives, and felt that they wanted to become
capable of providing such care.
(4) [a sense of satisfaction in mastering the nursing
process] With the instructor’s advice, students conductedassessments while considering speci ic issues of individual
terminal patients, such as the physical and treatment plans
and lifestyles. Based on the assessment results, the students
provided and evaluated symptomatic care that prioritized
the patient’s wishes to the best possible extent to minimize
the patient burden and suffering. Through this experience,the students became aware of their growth as nurses.
(5) [importance of each day in terminal phase nursing] At
the same time, the students struggled in their interactions
with dying patients for whom their previous experiences
and knowledge were insuf icient to provide care. However,this experience changed the students' view: they learned
the importance of daily nursing interventions andinterdisciplinary approach and wanted to apply thisexperience to their future nursing practice.
(6) [regrets about terminal phase nursing] Moreover,students had regrets that they were not able to provide thebest care in coordinating the discharge of terminal phasepatients or their deaths and had internal con licts about
ethical issues in the terminal phase that affected thepatients and their families. This encouraged them to further
their studies after the practicum; they wished to learn aboutcare methods and ways of thinking as a nurse throughliterature and reports, re ine their own nursing and ethicalviews, and apply them in providing care to other terminal
phase patients in the future.
Discussion
1. Findings from the students’ learning process:The results of our analysis revealed that the process oflearning palliative care by the university nursing students
could be divided into two categories: key components
common to all students, i.e., [a sense of inadequacy in theability of holistic integration], [realization of a deepened
relationship], and [bene its of care (were manifested) inpatients’ calmness], and those that varied between
students, i.e., [a sense of satisfaction in mastering thenursing process], [importance of each day in terminal phasenursing], and [regrets about terminal phase nursing].
Key components of the learning process: Of the threecommon items that compose the core part of the learning
process, [a sense of inadequacy in the ability of holistic
integration] and [realization of a deepened relationship] areinter-related. The symptoms of terminal phase cancer
patients and the physical assessment of these symptoms
should be multi-faceted and need to be investigated not only
for the primary disease, which is cancer, but also forEubios Journal of Asian and International Bioethics 31(3) (March 2021)
comorbidities, their symptoms, and adverse events
associated with the treatment. Moreover, understanding thetotal pain experienced by the patients is essential for
providing nursing care for patients who are aware of deathlurking behind them 11. In other words, nurses are required
to turn their interest toward the patient while conducting
holistic assessment, be recognized by the patient assomeone who understands them and build a relationship oftrust to satisfy the care needs of the patients 12. Somestudents in this study also seemed to have been able todeepen their relationships with the patients andunderstood the patients’ thoughts and feelings, such as theirregret in not being able to be there for their children as theygrow or in having sacri iced their careers, while having a
sense of inadequacy in the ability of holistic integration.
One of the abilities required in nurses involved in palliative
care is to provide comforting care to patients 13. Even
though it is not always easy to evaluate the patient’s
comfort, many students experienced that the patients’physical and emotional suffering changed into a calm state
after they practiced physical and emotional care. In otherwords, calmness in the patients can be assessed as thestudents’ practice care and serves as an important indicatorof the bene its of palliative care.

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Learning process components that vary among students:
Next, we found that students diverged into either of thefollowing three different paths in the latter half of thelearning process: [a sense of satisfaction in mastering thenursing process], [importance of each day in terminal phasenursing], or [regrets about terminal phase nursing].
First, students who achieved [a sense of satisfaction inmastering the nursing process] were able to practice thenursing process in the terminal phase with advice from the
instructor, which was one of the goals of the practicum, andfelt that the practicum allowed them to grow as nurses. The
students who were able to acquire this learning experience
were likely to have a high level of satisfaction and sense ofachievement, given that they were able to attain the nursing
process, which was one of the learning objectives. This
group of students was thus likely to have gained con idence
as a nurse working with patients in their terminal phase.
Meanwhile, students who experienced the [importance ofeach day in terminal phase nursing] were struggling in theirinteractions with patients near death, for which theirexperiences and knowledge were not very useful. Students’experiences of this challenge, however, allowed them toreach a new level in understanding the importance of daily
nursing interventions and patient care by the healthcare
team. Students who learned this are likely to haveexperienced a sense of helplessness and limitations inproviding care for terminal phase patients by individual
nurses and acquired new viewpoints and interpretations,such as the importance of daily nursing and team care.
However, a previous study has reported that students feel
unprepared for dealing with the issue when they encountera patient death14, and thus, it is challenging to identify the153

speci ic educational support needed by them and improvethe methods and contents of support.
Students who experienced [regrets about terminal phasenursing] felt that they were not able to provide suf icientcare. A previous study reported that students feel gloomier
as they gain more knowledge in palliative care in thepracticum 15, suggesting that students who interacted withterminal patients and gained knowledge, became aware of
the fact that the patients were close to the end of life. It is
likely that students may question themselves strongly about
the way they interacted with the patients thinking it was ofno bene it or they could have done something more for thepatient. Having such thoughts is a speci ic phenomenon topracticums involving terminal patients and may re lect theanxiety and fears that students may have about caring forterminal patients 16.
We also observed that some students felt con licted about
ethical issues surrounding terminal care. In basic nursing
education, nursing students are expected to acquire ethicalviews appropriate for the nursing profession, and emphasis
is placed on striving to understand the situation or context
of the patients and their families17. Students in this study
interacted with patients and their families genuinely andtried to understand their situations and contexts, which
created an awareness of ethical issues. However, ethicalissues in palliative care involve the patient’s life or deathand can threaten patient autonomy or dignity. A previous
study has reported that many students tend to fall silent
when faced with an ethical issue during a practicum 18.
Similarly, the results of our study suggest that students
faced with ethical issues during practicum were unable topractice coping behaviors and were instead left struggling
internally.
2. Implications for palliative care education
As mentioned above, various dif iculties and challenges arepresent in the students’ learning process in practicum,indicating that appropriate guidance is necessary to tackle
them. Students who experienced the dif iculties of dealing
with a dying patient and regrets about terminal phasenursing are likely to be left with a low sense of satisfactionor achievement from the practicum. A previous study has
stated that students who were involved in caring for dying
patients felt emotionally exhausted as they re lected on
their practicum after it was over19. Then, it is possible thatexperiences during the practicum instill anxiety and fear
about caring for terminal phase patients in some students.
It is therefore the responsibility of the instructor to support
such students to discover knowledge on their own andencourage them to learn how to interact with palliative carepatients positively. However, the instructors themselvesoften feel the dif iculties and limitations of care for patientsand do not have the con idence to instruct the students
about terminal cancer patients 20, which warrants further
investigations for ways to support the instructors.
Re lections and dialogues adapted for individual learning
processes are considered effective educational methods tosupport instructors. Re lection refers to a pattern of154

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

thinking back over experiences in nursing practice and thethoughts and emotions they had to improve nursing
competence21. Introducing re lection in instruction of
palliative care should allow students who had trouble
caring for dying patients and regrets to verbalize theirthoughts and con licts. By having the instructor listen tothem, the students themselves may go through a catharsis.
Furthermore, simulations of how they would be able to carefor similar terminal patients may allow the students to
sublimate their thoughts into motivation for future learning.
Moreover, conducting discussions with the instructor
focusing on ethical issues to investigate solutions for
optimal patient care may be bene icial for students facing
ethical issues during practicum. A previous study has
documented that instructors need to explain ethical issues
and make students think about how to deal with issues as
nurses 22. Such a support may urge the students to search
for new methods to cope with ethical issues or may lead tothe resolution of ethical con licts. As our study showed,
instructors’ support should be adapted to the students’learning process and motivate them to initiate their own
learnings and discoveries.
Conclusions
Two challenges in palliative care courses in basic nursing
education were identi ied: (1) The need for speci ic
educational support for students who had trouble ininteracting with dying patients and regrets about terminal
phase nursing, and (2) the lack of known coping methods
effective for students who experience internal con licts withethical issues surrounding patients in the terminal phaseand their families.
Implications for palliative care education included:
Students should be encouraged through re lection andconsultation to (1) sublimate the dif iculties theyexperienced in interacting with dying patients and regrets
they had about terminal phase nursing into motivation forfurther learning, and (2) explore the coping methods to deal
with ethical issues and resolve their ethical con licts.
Acknowledgements
This study was supported by a Grant-in-Aid for Early-Career
Scientists for FY2017-2018 (Category B).

References

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1) Kokuritsu gankenkyu senta ganjohosabisu. Saishin gantoukei. 2019-10-4
https://ganjoho.jp/reg_stat/statistics/stat/ summary.html(Accessed
9-1.2020）(in Japanese)2) Ministry of Health, Labour and Welfare. The Basic Plan to Promote
Cancer Control Program, https://www.mhlw.go.jp/ ile/06Seisakujouhou-10900000-Kenkoukyoku/gan_keikaku 02.pdf (inJapanese)3) American Association of Colleges of Nursing. (2000). Peaceful Death:
Recommended Competencies and Curricular Guidelines for End-of-Life.
Nursing Care.1-6.
4) Japan Association of Nursing Programs in Universities (2018). Kango
gakushikatei kyouiku ni okeru kea kompitenshi to sotsugyoji totatsu
mokuhyo.31-33 (in Japanese)5) Shimizu S. (2010).” Palliative Care Education” for Nursing Students:
Provision. The Japanese Journal of Clinical Research on Death and Dying,
33(1):101-106. (in Japanese)

6) Gillan PC, van-der-Riet PJ, Jeong S. (2014). End of life care education,
past and present: A review of the literature. Nurse Education Today,
34(3):331-342.
7) Edo-Gual M, Tomás-Sábado J, Bardallo-Porras D, et al. (2014). The
impact of death and dying on nursing students: An explanatory model.
Journal of Clinical Nursing, 23(23-24):3501-3512.
8) Ito M, Kodama M. (2011). Perspectives and implications of psychoeducational support for student nurses during a practicum in caring fordying patients. Tsukuba Psychological Research, 42:77-86. (in Japanese)
9) Ueda C, Ueda I, Hatano FH et al. (2012). Palliative Care Unit Learning
Among Student Nurses through Clinical Practice: An Analysis of Their
Concept on Life, Death and Nursing. Kansai iryo daigaku kiyo, 6:51-58.
(in Japanese)10) Yamaura H. (2012). Shitsuteki togo nyumon Kangaekata to tejun. Tokyo,
Igakushoin. (in Japanese)
11) Saunders, DC (eds). (1984). The Management of Terminal Malignant
Disease,2nded. London. Edward Arnold.
12) Tamura K, Kawa M, Morita T(eds). (2017). Kango ni ikasu supirichuaru
kea no tebiki, 2nd ed, Tokyo, Seikaisha, 78-80. (in Japanese)13) above 3)14) Johnson A, Chang E, O’Brien L. (2009). Nursing the dying: A descriptive
survey of Australian undergraduate nursing curricula. International
Journal of Nursing Practice, 15 (5):417-425.
15) Österlind J, Prahl C, Westin L, et al. (2016). Nursing students'
perceptions of caring for dying people, after one year in nursing school.
Nurse Education Today, 41:12–16.
16) above 8)17) Davis AJ, Tschudin V, de-Raeve L (Konishi E, supervisor of translation)(2008). Kango rinri wo osieru・manabu Rinri kyouiku no shiten to
houhou. Tokyo, Nihon kango kyokai shuppan : 188-206. (in Japanese)18) Epstein I, Carlin K. (2012). Ethical concerns in the student/preceptor
relationship: A need for change. Nurse Education Today, 32(8):897-902.
19) Huang, X. Y, Chang, J. Y, Sun, F. K, et al. (2010). Nursing students'
experiences of their irst encounter with death during clinical practice in
Taiwan. Journal of Clinical Nursing, 19(15-16):2280-2290.
20) Aoki S, Ohara K. (2008). Anxiety felt by trainers who teach nursing
students in charge of terminal cancer patients. Journal of Nursing
Research Society of Kochi University, 2(1): 3-13. (in Japanese)21) Tamura,Y. Ikenishi, E. (2014) Kango no kyouiku jissen ni ikasu
rifurekushon. Tokyo, Nankodo, 63-70. (in Japanese)22) Tsuruwaka, M. (2015) Crucial ethical problem for Japanese nursing
students at clinical settings. Journal of Nursing Education and Practice,5(12):17-24.

Legal and social perspectives on
euthanasia in India- Deepa P, Ph.D.
Assistant Professor, Department of Philosophy, Calicut UniversityKerala
Email: deepakallayi@gmail.com

Abstract
The legal and social perspectives of euthanasia have been widely
debated in India since the 1990s. The Indian constitution is astrong pillar that supports a peaceful society and practice ofmorality. This paper deals with the legal and social perspectives of
euthanasia in the context of India. Article 21 of the IndianConstitution assures that every Indian citizen has the right to livewith dignity. While it provides all citizens the right to life, somesocial customs like ‘thalikoothal’ in Tamil Nadu southern part ofIndia and ‘sallekahana’ (fasting unto the last) among Jain monks in
Banaras Northern part of India are practiced. These are thechallenges to the Indian Constitution and individual rights.
Sallekhana is a religious custom but ‘thalikoothal’ is a social
custom. This paper discusses social and legal points of euthanasia.
The landmark case of euthanasia in the Indian Supreme Court inEubios Journal of Asian and International Bioethics 31(3) (March 2021)
2007, and the plea of Nurse Aruna Shangbarg and permission for
passive euthanasia are discussed.

Introduction
The constitution is a strong pillar of human societies,
especially in India. It is an imperative for human beings toabide by the law to have a peaceful society; otherwise,
society will be in chaos. Every action in a society can beconsidered either right or wrong. Right action gets theapproval of the society whereas wrong action gets
disapproval from the society. To prohibit wrong actions by
an individual and to protect others from being a victim of it,
state laws have been framed. If an individual performs anaction not approved by the society, such actions are
considered as wrong actions and the state enforces laws toprevent such actions, either by punishment or byreformation. The rationale behind state’s law and order is tomaintain a peaceful atmosphere in the society and to help in
upholding good human relations. Hence, an attempt toproblematize dilemmas involved in legalizing euthanasia asright or wrong is considered here.

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Euthanasia from a legal perspective
Every profession as a wheel revolves with certain ethicalcodes as its fulcrum. It implies certain imperatives are
ethical and certain imperatives are legal and protected by
the state. Medical profession is one such profession which
encompasses both ethical and legal codes. The issues
pertaining to euthanasia raise questions like: Do thephysician, patient or relatives have the right to decide upon
the application of euthanasia? It is the inal decision of anindividual during the last stages of his/her life, so it is ofundue importance to analyze the issues involved inlegalizing euthanasia, so that it can be prevented from being
abused. There is a strong opinion that legal permission isoften necessary in application of euthanasia. Other groups
may say there is no need for legal permission to do
euthanasia. However, if euthanasia is legalized then there
may be a solution for the questions like whether theindividuals or patients have the right to live or die. If
legalized, there is immense possibility of abuse; if it is notlegalized, then the patient must continue suffering.
The acceptance or rejection mainly depends upon theculture and moral norms of that country. India rejected thelegalization of euthanasia even though it accepts passive
euthanasia. In India, irst plea came in 2004 when a mothermoved to court for her twenty- ive-year-old son Venkatesh,
who was a former National Chess Champion. He wassuffering from Duchene’s Muscular Dystrophy; in his inaldays he was admitted to hospital and survived with the helpof ventilator support. However, he was conscious and fully
aware of his disease and death. So, the mother with theconcern of her son approached the Andhra Pradesh (a statein India) High Court for allowing him to die. Simultaneously,
she insisted on her son’s wish to donate his organs. In thisprocess she approached Mohan Foundation for organ
donation but was refused, because the patient was still
alive, he was conscious and brain death didn’t happen tothat patient. The reason behind their rejection was the rule155

of organ transplant act 1995 which had no provisions thatallowed individual to donate organs when alive.
Another landmark case from India was that of Aruna
Ramanchandra Shanbaug who worked in King Edward
Memorial Hospital Mumbai. She had been attending thenight duty as nurse. A male sweeper working in the same
hospital attempted to rape her. He tried to kill her and tied
her neck with dog chain. Because of this, the oxygen low tothe brain was stopped. She became paralyzed and blind; she
can’t speak and move. Her current state is PVS and from1973 onwards she is in vegetative state. Due to thiscondition, her friend iled a petition to demand theapplication of euthanasia. It has raised a legal question in
front of the India’s Justice. The court suggested threephysicians to examine her. After examining the report, theSupreme Court accepted passive euthanasia. It has been
accepted only after thorough investigation into Aruna’s
condition. As per procedure the court appoints respective
physicians for studying the patient’s condition. Depending
upon the report of the physician the court may decide
whether euthanasia may be applied or not. For the irst time
the Indian Supreme Court was in a dilemmatic situation in
Aruna’s case whether euthanasia must be sanctioned or not.
In her case the law commission mentioned three things.
First, generally the law commission in India maintains threeimportant parameters in any plea against euthanasia, suchas three reputed doctors to be nominated by the Bench after
consulting such medical authorities/medical practitioners
as it may deem it. Preferably one of the three doctors
should be a neurologist, one should be a psychiatrist, andthe third a physician. Secondly, if the doctor agrees thepatient can approach the government or the constitution.
Third one is that the government or constitution will
appoint a committee of three members. In normal cases theapplication of mercy killing or euthanasia to the terminallyill person is considered a crime in India. Accordingly, theSupreme Court will not entertain any such plea in theadministration of euthanasia. However, in the case of Aruna,the Indian Supreme Court accepted passive euthanasia withsame terms and conditions (Venkatesan: March 2011).
The legal aspects behind the two cases are different; in
Venkatesh (Prabhakar: Indian Express 2009) case he died
before the court result. But in Aruna’s (Sudha U; The Hindu
2010) case still she is living in PVS. In Venkatesh case there
is a legal problem, but it did not affect him before his death.
But in Aruna’s case, legislation accepts only passive
euthanasia that is the result of the thorough examination. In
both cases it shows that Indian Constitution is against
euthanasia. The Indian constitution 21st article states that it
doesn’t allow killing of any form. In Indian constitution, thearticle 21 mentions the right to life and not right to die orkill. So, suicide is considered illegal in India. “Right to life
under article 21 is something more than mere breathing.
The Supreme Court has held in Francis vs. Union Territory(A I R 1981 SC746) the right to life would include the rightto live with human dignity; with this interpretation given to
article 21, the door was open for various kinds of rights

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which will have to be read into the right to life with humandignity” (Constitution of India).
According to the Indian Penal Code 186 section 300,
the act of intentionally killing others is a murder. If anyone
did mercy killing on the request of the patient or relatives it
would be a homicide. In other words, the person will bepunished under the Indian Penal Code Section 304 on thecase of homicide. Encouraging suicide is also an offence inIndian Penal Code under section 305 and 306. Based onthese legal grounds, Aruna’s friend plea for euthanasia isconsidered as murder. Because she is in PVS and she cannot
respond to her wish.
Chief Judge of Indian Supreme Court Justice Markandey
Katju has given the reasons for not allowing euthanasia as
well as rejecting to legalize euthanasia of Aruna Shaubhug.
He said: “We are also concerned that once this is allowed,
there will be too many such requests from relatives. There is apossibility that relatives in collusion with some doctors may
bump off the patient claiming he/she is in a P V S though he/she may not be really so” (Padma P; The Hindu 2011)
Y.G. Krishnamurthy, advocate of the Andhra PradeshHigh Court stated against the legalization of euthanasia as:“I don’t agree with euthanasia- passive or active. Everybody
has a right to live. No one should be allowed to kill himself/
herself or give permission for another person to die. Suffering
is not an excuse to take away God-given life. Dignity in deathis surrendering to God’s will, being patient and going when
He takes you away” (Padma P; The Hindu 2011). Based onthese reasons there is always an opposition in legalizing
euthanasia. On the contrary there are those favoringeuthanasia because of the pain, suffering and mental trauma
by the individual.
The above-mentioned arguments are against
legalization of euthanasia for slippery slope argument. If
euthanasia is legalized, then there is a possibility forphysicians violating their duty. Sometimes the case iled by
the court will be either from patient side or from therelative’s side. The patient knowingly approaches the court
for applying euthanasia, e.g. in Venkatesh’s case. Then, if thelegislation gives permission to that patient sometimes thiscan be taken as the base behind the coma patient’s deathe.g. in Aruna’s case. In the irst case, Venkatesh knowingly
approached the court for euthanasia with the help of his
mother. It shows the intention of the patient. But in Aruna’scase, her friend approached the court without her concern.
So, it shows that the intention of the patient is abstract. So,
there is a possibility for different situations. The slippery
slope argument gives chance to the patient more than thelegal permission. So, this will change patient’s death fromthe “better off dead” (Grisez & Boyle; 2008) to “better off
killing”. Thus, the society, medical profession and relatives
have a risk for corruption. So, legalizing euthanasia iswrong. There are two sides of philosophical argument
against the legalization of euthanasia.

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Euthanasia from a social perspective
Euthanasia as a social issue has its in luence on cultural,
economic, and political aspects. It re lects on the liberty ofthe society. Socially the individuals have some ixed values
and norms, and the individuals must follow those morals ina society. The dying person and the relatives of the patientalso must follow certain social norms and values. Even
though, the patient is suffering from painful disease anddistress; his relatives must consider the social norms. In any
society there are some beliefs about the individual’s life,
which can’t be overruled. In this situation if euthanasia islegalized it will lead to social controversies. The loved one’s
suffering and distress will be a painful sight to the relatives,
but from the legal perspective there is no place for moral
norms and values. A good number of old age homes, homes
for rehabilitation centers and mentally challenged havebeen emerging in the contemporary society. The brutality ofliving during the pre-civilization period might creep in theexisting situation warning about the dif iculties inadministrating euthanasia which may create a chaos in thesociety. In this context ethical problems will arise in mercy
killing.
Good family and society are the base of individual’s
good action and support. It includes emotional, practical,
and inancial support of the individual. In near future, there
might be a situation where human beings may beconsidered as mere specimens in laboratory experiments inthe name of euthanasia. In this way, euthanasia may open
the gates in letting the social evils to its abuse and threat,
for the human existence in the society. A clear discussion
pertaining to euthanasia is important in this perspective.
The same case can be viewed from a sociological point ofview.
Thalaikoothal is a social practice behind which there isa motive in killing the elderly people. In Tamil Nadu,
Virudhunagar district and some other southern parts of thestate there is an established social practice named
thalaikoothal. This is applied on the elderly or to theterminally ill people. These elderly people are given aceremonial oil bath after which they will be fed tendercoconut water which will cause pneumonia and eventuallylead them to death. Sometimes they will add poison for
hastening the death. Their main motive is grabbing theproperty. One such incident was reported in Virudhunagar
district where an eighty-year-old man escaped from his
house because his children were going to conduct thethalaikoothal for him. The whole family members wereinvolved in the unethical social practice. This in turn implies
that if euthanasia is legalized, there is a possibility of
misusing them on the innocent people.
Lack of awareness is the irst reason for misusing
euthanasia and most people don’t have the knowledge
about euthanasia. Some people are not educated and are
exploited in speci ic situations. Sometimes patients seem tobe a burden to the relatives, so they will apply euthanasia
without knowledge of the patient. The patient may not beaware of what is going to happen, and he may die
unknowingly. The aim of the relatives may be grabbing theproperty and relief from the burden. Because of thesereasons poor individuals may lose their life. According to Dr.
Amit Agarwal, oncologist of Fortis Hospitals Noida Delhi,

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India expressed this dilemma of the lay man’s awareness ofeuthanasia as absolute lack of public awareness and clearcut legal directions on end-of-life terminal care. Whenever
we are in a situation of aggressive, life sustaining treatment
in a terminally ill patient, we honestly tell the patient andthe family and take into consideration what the patient
would have wanted. We also do everything to make thepatient as comfortable and pain- free as possible (Sudha U;2010) .
In social life it is often considered as a burden for thefamily and the individual when it comes to the case of adiseased and disabled person. So, their life may become
devalued as they are a burden to their relatives. They
themselves feel that they are burden to their relatives and to
the society. Because of the helplessness in life, they thinkthat they are not useful to the society. Since their life is notvaluable, they are forced to die. Here, the patient’s
autonomy is of no value since the inal decision is taken by
the relatives. The prime concern of society is about
individual’s quality of life. Therefore, the society has themost responsibility to protect and promote the quality oflife. The best option is to choose death. Death is the only
way of escaping from the intolerable situation and from thesuffering of painful disease. Here, the patient may opt
voluntarily or knowingly but not with ‘coercion’.
The government and the society have the responsibility
to secure the life of disabled persons. Some special shelters
must be allotted for disabled people. However, this may
require isolation of the disabled people like the case of AIDS
patients. Once society starts isolating the AIDS patients, itwill become practice. People still think that AIDS is avulnerable disease. This isolation will detach the connection
between ordinary men and the patients. This type of
isolation will affect the patient psychologically. So, they will
think that there is no hope of recovering, and they will be
depressed and forcefully take the decision for applying
euthanasia. But the society also has the responsibility tohelp the isolated patient. This isolation of the patient orelderly people motivates them for dying. The society has the
responsibility to protect the elderly people. One such
isolated place is an old age home.
The painful sight of the patient may create sadness in
the life of their close relatives due to the lack of emotional
support and inancial support. The emotional attachment of
the family members may create worries to the disabled
person. It will be one of the reasons for choosing euthanasia
by the patient. The question is who will performeuthanasia? Usually, doctors practice it in somecircumstances. Sometimes based on the patient’s request,
others might perform euthanasia. However, once euthanasia
is legalized, a dilemma will be opened. Applying euthanasia
can be justi ied under some circumstances in the medical
ield. If many people want to apply euthanasia it leads tomany controversies in the society. The government must
identify a speci ic place to perform euthanasia, like hospitalor some other place. If someone kills the other person forthe sake of property, the government will not be able tosentence that person, since it has legalized killing andff

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cannot punish the people. All these types of dilemmas are to
be encountered by the government.
If euthanasia is legalized socially, it will be misused. In
the name of euthanasia, the patient maybe exploited for thesake of organs. The world we are living is turning out to be
more materialistic, sel ish, and detached where everyone islooking only for money and nobody bothers about love andemotional feelings like bond and attachment. Dr. Nagaraj
Huilgol, Chief Oncologist at Nanavathi hospital andPresident of right to Die with Dignity, says “involuntary
euthanasia must never be allowed. There are several dangers,
including euthanasia to harvest organs, which is criminal”(Nagaraj; Decan Chronicle 2011).
The main trouble which the society will be facing is thedifference between haves and have-nots. There is a chancefor killing the have-not people for many purposes. In thecontemporary world many people are living on foot path.
The government and society don’t accept them as citizens.
Sometimes they may be killed for political reasons. The
societies should give importance to the progress of therehabilitation centers for old people, for children, forpatients and mentally challenged persons. The people also
should feel responsible along with the government. If
euthanasia is practiced, then there may remain no values inthe society. In Nazi Germany, euthanasia was practiced forkilling people with disease. Perhaps Hitler’s aim was toreduce the economic burden but here the aim is different. If
all these problems can be overcome, then there is a genuine
possibility where euthanasia can be practiced in the interestof the patients like in Aruna’s case.
At the same time both for the relatives and for the
medical institutions, the patient may become a burden. In
these circumstances, the physician advises to relatives totake back the patient. If relatives give the plea to theinstitution, then they can allow the patient to stay in thehospital. Here, both the relatives and the institution may
feel the burden. One of the reasons is inancial. The All-India
Institute of Medical Science New Delhi, India reports thatamong the trauma patients, 70 patients out of 200 are in avegetative state. The family members are not interested intaking the patient back home because of economic burden.
Sometimes hospitals also ight to send the patient home.
They don’t want to permit the patient to stay till his/her
death because it will be a burden to the institution. One ofthe patient’s mother asked the duty doctor “why don’t you
keep my son Naushad here for the rest of his days? How will I
take care of him at home?” (Rashme; Decan Chronicle 2011).
The patient’s treatment would cost around Rupees 5000 per
day and can’t be afforded by the hospital as well as themother. Now the Indian family system has become nuclear
so they are not equipped to take care of someone who willneed lifelong care. And lower-income families will not beable to take the responsibility of the patient. These are thefew genuine situations where euthanasia can be justi ied.
Conclusion
India has given importance to its citizens through thesociety and their legal bindings. Hence, India has accepted158

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

the practice of passive euthanasia; however, the social issue
like thalikoothal which is practiced in certain places of south
India is a challenging situation. The Supreme Court of India
had expelled active euthanasia and accepted passive
euthanasia based on the landmark case of Aruna. It has
mentioned that “right to life: including right to live withhuman dignity would mean the existence of such right up to
the end of natural life, which also includes the right to adigni ied life up to the point of death including a digni ied
procedure of death” (Judgement, Writ Petition (civil) No.215
of 2005). Court holds that right to die with dignity is a partof the basic right to life. The judgement is “the right of dying
when life is ebbing out in the case of a terminally ill patient ora person in permanent vegetative state, where there is norecovery, accelerating the process of death for reducing theperiod of suffering constitute a right to live with dignity”.
(The Hindu; March 10, 2018). In the case of thalikoothal, in
my view, it is also a passive involuntary euthanasia.
However, the difference and distinction are that thalikoothal
is non-voluntary or there is no mention about dignity of life.
It is a concern on the part of victim’s relatives for reliving
the burden as well as grabbing property.
References
Constitution of India, Part III, Fundamental Rights, Right to Freedom, Article
21, pp.3-4.
Grisez G & JM Boyle, Jr., Life and Death With Liberty and Justice – A
Contribution to the Euthanasia Debate, University of Notre Dame Press,
London, 1979, p.173, Cited by Robert G. Richardson, The Politics ofEuthanasia ( PhD thesis), University of Adelaide, 2008. p.74.
Nagaraj Huilgol, “Doctor Have No Right to Kill”, Deacon Chronicle, March 13,
2011, p.1.Chennai.
Padma P. “Who Has the Last Word?”, The Hindu, Sunday Magazine, March
20, 2011, p.1. Chennai
Prabhakar R, “SC Issues Notices on Mercy- Killing of Nurse”, Indian Express,
December 7, 2009. Chennai.
Rashme S, “Right to Live, Right to Die”, Deccan Chronicle, March 2011. p.1.
ChennaiSudha Umasekar, “Landmark Cases in India”, The Hindu, February 14, 2010.
ChennaiSudha Umasekar, “The Fight for Dignity in Death”, The Hindu Daily News
Paper, February 14, 2010, p.6.
Venkatesan, “Supreme Court Disallows Friend’s Plea for Mercy Killing of
Vegetative Aruna”, The Hindu, March 8, 2011, p.12. Chennai.

Assisted Reproduction and theJapanese Paradox- Silvia Croydon, D.Phil. (Oxon)
Graduate School of Human Sciences, Osaka University. Suita,
Osaka, Japan
Email: croydon@hus.osaka-u.ac.jp

Abstract

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Japan represents something of a paradox when it comes to assisted
reproduction. On the one hand, because of the vast size of its
Assisted Reproduction Technologies (ART) sector, it would benatural to expect there to be many cases of mishandling or
mistreatment that come to surface. Yet, this does not appear to be
the case. The system seems to run surprisingly smoothly, at leastas far as it could be observed from the reportage in the media.
Indeed, one would be hard-pressed to ind more than a handful ofscandals there that involve the application of ART. With a view toilluminating the mechanism through which the perceived
smoothness of operation in Japan is achieved, the present article
puts the spotlight on the compilation of guidelines andrecommendations for ART created and implemented by the Japan
Society of Obstetrics and Gynecology. I argue that the ef icacy inoperation notwithstanding, the said regime is not a substitute forformal framework for ART that is promulgated by the Japaneseparliament.

Introduction
Japan is an in vitro fertilization (IVF) giant (taigai jusei
taikoku) and its heavy reliance on assisted reproduction
more generally is well-documented. As the nation with thegravest demographic crisis, where the population size isshrinking at a striking pace, it is often reported with regards
to Japan that it has a persistent problem of low fertility andthat the portion of newborns conceived through IVF is
growing due to an ever-increasing number of people
marrying later in life. Within the domestic news landscape,the Japan Society of Obstetrics and Gynecology (JSOG)
survey result was widely publicized recently of a record
424,151 IVF procedures having taken place in 2015,
resulting in 51,001 births, which is another record (Japan
Times 2017; Cook 2015). Today, most Japanese would beaware that typically at least one child in each school-classhas been conceived via IVF.
Japan’s utilization of assisted reproduction is not
merely heavy; it is, in fact, unprecedented and unparalleled.
Indeed, Japan resorts to IVF like no other country in theworld. According to data published in 2016 by theInternational Committee for Monitoring Assisted
Reproductive Technologies, in all the three years underinvestigation (2008, 2009 and 2010) the number ofaspirations (egg retrievals for IVF) performed in Japan wasan order of magnitude larger than that of any other country;
indeed, a difference was recorded of a whole digit between
Japan and the second biggest utilizer of IVF – the UnitedStates (Dyer et al. 2016). A further indicator of just how
much activity there is in ART in Japan is the comparison
between the number of registered facilities that provide
such treatments. According to Franklin and Inhorn (2016),
there were somewhere between 600 and 618 registeredsuch institutions in 2009. To put this number into
perspective, the institutions of such character registered in
the United States for the same period were about threetimes less, even though the latter country is twice as
populous as Japan. This Japanese vibrancy in ART has also
been picked up by the foreign popular media, with the
Economist, for example, publishing a column in May 2018
entitled “No country resorts to IVF more than Japan…”(2018). “Nestling among a plantation of high-rises in abusiness district of Tokyo”, the column goes, “[Kato Ladies’
Clinic – the world’s busiest] clinic implants fertilized eggs inan average of 75 women a day” (Ibid.).
Given this status as the world’s most heavy-weight
utilizer of ART, it could be reasonably expected for Japan toregister a substantial number of cases involving

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
mismanagement, mistreatment or scandals. This, however,does not appear to be the case.
Of course, there are some prominent instances wheredevelopments have gone wrong. A recent example thatcomes to mind is that of Eric Young, about whom it was
revealed in court in 2014 that his wife had taken,
unbeknownst to him, her lover’s sperm to the fertility clinicthat treated them (Adelstein 2015). The veri ication
procedures in this instance could be legitimately found to bequite lacking. Furthermore, most recently, in January 2020,
it reached the news that a fetus-reduction surgery had went
awry on a woman in her 30s in Osaka, whose ovaries had
been stimulated (as in IVF), only with the eggs not being
collected for ex vivo fertilization, in order to increase thechance of her conceiving (Asahi Webnews 2020). The
outcome of the ill-managed procedure was that all of theresultant ive fetuses had died, and as for her legal battle
that the woman led – on the grounds that “there is noevidence that there is suf icient established medical
knowledge about this procedure” on the basis of which thedoctor in question could be found to have been negligent,
she received the Osaka District Court’s rejection of her
23,000,000 yen compensation claim. Prior to these two
scandals, perhaps the one that received most attention
post-2000 is the discovery of human fetuses among theordinary refuse in Yokohama City Hospital (Yokohama
Kakuritsu Byōin) (Sleeboom-Faulkner 2008).
It is impossible to directly compare the frequency ofsuch events in Japan and in other countries with signi icant
appetite for ART. For a start, it is quite possible, with regard
to any jurisdiction, not just Japan, that the number ofmishaps surfacing is nowhere near that which actually takes
place. Nonetheless, to the extent that it could be ascertainedby anyone following developments in this areainternationally, the number of events of such character thatreach the media in Japan seems to be strikingly low,
especially, as explained above, given the exceptionally highrate of ART utilization. Indeed, on the background of the
sheer volume of ART cycles in this country, theuneventfulness in operations could be construed as
something of a feat.
So what mechanism is accountable for this success inrunning the ART sector? This article brings to attention theinformal framework that is in operation for ART in Japan
composed of voluntary guidelines and recommendations by
the JSOG – the professional medical society whose members
are at the frontline of infertility treatments. After describing
this regime and discussing several aspects that relate to theobserved outcome of general order and practitioner
compliance, I proceed to argue that the absence of a law
enacted by the people’s representatives in parliament is still
not justi ied.

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The JSOG regime
Despite the absence of an ART law in Japan, it is not the casethat the country is the Wild West in terms of ART practices,with clinicians having the freedom to do whatever they liketo patients and the latter having to fend off for themselves.

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Indeed, most practitioners in Japan do not feel like they
have a freehand in patients’ treatment; they would reportthat their actions are closely overseen by the JSOG, withhaving to report each case, and there also being acompilation of about 20 guidelines (on issues ranging fromtreatment of the embryo, cryopreservation of gametes, preimplantation genetic diagnosis, sex selection, etc.), that they
are expected, as members of that Society, to follow. This
informal regulatory regime, the architecture of which
emerged gradually since the irst cases of IVF application in
the country, as well as the threat of expulsion from theSociety if found in breach, has to an extent succeeded in
producing a standardization of treatment for patients sothat they do not have to worry so much that they might
receive a vastly different treatment depending on the facility
they choose to walk into.
On the issue of the JSOG holding its members in a tightgrip through the threat of expulsion, there have been only
two reported cases of this having happened, the doctors inquestion being Yahiro Netsu from Nagano prefecture’s Suwa
Maternity Clinic and doctor Tetsuo Otani from Otani Ladies
Clinic in Kobe. As far as doctor Netsu is concerned, his
breach of the JSOG guidelines for the irst time in 1998 (hewent against JSOG again in 2001) involved conception
through egg-donation within a family. i.e. between sisters.
As Gunning has argued, “he decided to put his head above
the parapet … to provoke reaction” (2003: 760). In hisannouncement of the birth of these donor-egg babies, Netzu
explained that his purpose was to promote open public
discussion of the JSOG restrictions that he felt were
becoming increasingly inappropriate and out of touch withthe mores of the times. With regard to this, it is necessary tomention that a growing number of Japanese couples wereseeking abroad, particularly in the West Coast of the UnitedStates, treatments that JSOG prohibited – indeed mostly
gamete donation ones. Although Netsu was able to keep his
license to practice upon losing membership of the JSOG, hebecame embroiled in a long-term court battle with theSociety over the right of the latter to expel him, whereby hebecame resigned when the Supreme Court ruled against
him. This, and the fact that he eventually sought successfully
re-entry into the Society, has arguably served as a lesson forother physical practitioners.
The limits of the JSOG framework: Discussion
When it comes to good clinical practice, it is undeniable that
doctors are the best placed people to decide on it. Indeed,by virtue of their training and experience, they know bestwhat constitutes a safe and effective procedure. However, as
bioethicist Guido Pennings rightly points out, many of thequestions that relate to ART are not about safety andeffectiveness; they are about ethics (Pennings 2009).
What are the boundaries of acceptable family-building?
Should unmarried or same-sex couples have access to ART?
Should sex-selection be permitted? What is in the interest of
the child? Which inheritable genetic conditions, if any,
warrant screening of embryos so as to avoid the birth of anaffected child? Should a child be allowed to know its

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biological father or mother even if this clashes with thewishes for privacy of the donor? How should a balance bestricken between equity in access and cost-ef iciency?
Should sparse inancial resources be directed towards
young women who are experiencing dif iculties to conceiveor older ones who are almost out of time? Should a woman
be allowed to use her sister’s womb for conception if her
own has been removed due to cancer?
Doctors have no special expertise in ethics and areconsequently no more quali ied than the rest of us toanswer questions of such nature. It thus comes as highly
irregular that they should be made, even by default, thearbiters in this area. Simply being at the frontline of ART,
does not make them quali ied to answer the ethicalquestions at stake on our behalf. The JSOG might be anorganization that works in the public interest, but, in theend, it is composed exclusively of doctors and there is no
reason why the resolution to the questions above should be
skewed towards their moral views. The Japanese society ispluralistic and so it only warrants, if a democratic approachto ART is to be taken, that the de facto monopoly that
doctors hold over ART implementation is ended.
Beyond this need to open ART for input from thebroader society, there is also the issue of securing the rightto legal redress by patients who have been mistreated. As
Pennings again observes, even though “doctors are always
complaining that politicians are restricting their work too
much without knowing how the practice works”, this does
not mean that they should be left to devise themselves therules of clinical practice (2009: S17). The danger of doctors’
self-governance, as Pennings points out, is that it naturally
rarely includes punitive sanctions in cases of misbehavior or
non-compliance, or even if it does these are minimal.
Regardless of how low the number of ART plaintiffs in Japanis in practice, this does not absolve the legislature of the
responsibility to enshrine the rights of patients in law. It is amatter of principle that such legal protections are provided
and that respectful and good treatment of patients by
doctors is not left to be a question of mercy by the latter.
The basics of what patients are entitled to needs to bespelled out in law so that if it emerges that they are
unhappy about their treatment, the courts, as a third,
neutral party, could decide if any lines have indeed been
trespassed and provide relief to the patient. To the extent
that there is no formal ART legal framework in Japan, thestate has left patients vulnerable vis-à-vis the doctors, as thecourts do not have what they need to provide redress.
Finally, it could be said that it is in the interest of
doctors themselves to have their obligations towards
patients speci ied in law. Clearly, it is preferable and much
more comforting from the point of view of a physician tohave to rely on guidance for what their duties are towards
patients that has been approved by the people’s
representatives in parliament, as opposed to theircolleagues. The law carries legitimacy that goes muchfurther than that of the opinions of professional societies
and associations; the former is indeed recognized as the
position of the majority in that particular society, and thatcarries an enormous weight. This is not to even mention
that there might be multiple professional organizations’guidelines that could differ and clash in terms of what theyrecognize as acceptable practice. Whilst in Japan, as it was
discussed above, it is the views of the JSOG that are
generally sought and followed, there are a number of othersimilar organizations in the area of reproduction that issue
guidelines – Japan Society for Fertility and Sterility, Japan
Society for Reproductive Medicine, Japan Society for
Fertility Preservation, the Japan Society for Human
Genetics, to name just a few.
Conclusion
As I have argued in this article, however effective theregulatory infrastructure might be that guides obstetricians
and gynecologists in Japan in their interactions withpatients, it cannot be regarded a substitute for a formal legal
statute. Leaving the doctors to serve as the adjudicators inmatters relating to justice, equity and access to ART, thewelfare of the resultant child, and even the safety ofpatients, is arbitrary. The responsibility to decide on suchmatters is perhaps not something that the doctors
themselves want either, however sweet the position might
seem, to some from aside, or to some of the doctors
themselves indeed, of being able to yield such power. By not
promulgating a law in this area, the Japanese legislators are,in effect, forcing doctors to play a policy-making role. It isindeed, often commented with regards to this long-standing
legal vacuum in ART in Japan that it is due to “lazy politics(seiji no taiman)”, as the legislators are loath to addressquestions on which there are so many different views anddisagreements.
On this last point of legislating, it must be
acknowledged that there is currently an initiative inJapanese parliament that might inally bring the end of thestatus quo. Indeed, a bill relating to ART procedures has forthe irst time passed the House of Representatives and, as ofDecember 2020, is sitting in the House of Councilors. Even if
it passes this last hurdle, however (and it must be said that
there have been other bills in the past that have not made it
through parliament), the bill in question seems to be very
limited in scope, seeking mainly to clarify that the birthmother and the contracting father in cases of gamete
donation are the legal parents. Whilst this move iscommendable and the progress that the bill is making is
encouraging, since most other areas of ART practice remainbeyond its scope, its potential passage should be regarded
merely as a irst, modest step, and not the aim. All eyes mustremain focused on whether the “lazy politics” will end.
References
Adelstein, Jake (2015). “Japan still a long way behind fertility boom”. Japan
Times http://www.japantimes.co.jp/news/2015/06/06/national/
media-national/law-still-long-way-behind-fertility-boom/ (Retrieved on
September 12, 2020).
Asahi Webnews (2020). “Miscarriage after surgery to reduce the number offetuses: Compensation claim rejected [Taiji wo herasu ‘gensū shujutsu’ deryūzan: Isharyō motometa, uttae mitomerarezu]”. Kansai News
www.asahi.co.jp/webnews/pages/abc_4845.html (Retrieved on October
5, 2020).

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
Cook, Michael (2015). “5% of Japanese babies from IVF”. Bioedge
www.bioedge.org/bioethics/5-of-japanese-babies-from-ivf/12441.
Dyer, Silke et al. (2016). “International Committee for Monitoring Assisted
Reproductive Technologies world report: Assisted Reproductive
Technology 2008, 2009 and 2010”. Human Reproduction Vol. 31(7):1588–1609.
Economist (2018). “No country resorts to IVF more than Japan—or has lesssuccess”. http://www.geneticsandsociety.org/article/no-countryresorts-ivf-more-japan-or-has-less-success (Retrieved on December 2,2020).
Franklin, Sarah & Patricia Inhorn (2016). “IVF – Global Histories”.
Reproductive BioMedicine and Society Online 2: 1-7.
Gunning, Jennifer (2003). “Regulation of Assisted Reproductive
Technology: A Case of Japan”. Medicine and Law 22:751-61.
Japan Times (2017). “IVF accounts for 5% of babies born in Japan in 2015;
survey” www.japantimes.co.jp/news/2017/09/12/national/socialissues/1-20-infants-born-vitro-fertilization-japan-survey (Retrieved on
November 5, 2020).
Pennings, Guido (2009). “International evolution of legislation andguidelines in medically assisted reproduction”. Reproductive BioMedicine
Online 18(2): 15-8.
Sleeboom-Faulkner, Margaret (2008). “Claiming the futures of humanembryonic stem cell research in Japan: minority voices and theirampli iers”. Science as Culture 17(1): 95-7.

Bracing for the new normal or postnormal? Challenges and aspirationsof indigenous parents for educationof their children- Rogelio P. Bayod- Erikka June D. Forosuelo
Cor Jesu College, the Philippines- Jenny P. Morante
Department of Education (DepEd) Davao del Sur- Maribel C. Guerra (Corresponding author)
Cor Jesu College, the Philippines
maribelguerracjc01@gmail.com

Abstractf

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The most affected sectors in the sudden shift of curriculum of theeducational institutions in the Philippines due to the threat of
Covid-19 pandemic are the poor and the indigenous peoples who
are living in the hinterlands where access to basic services is still achallenge. As a result, indigenous parents are forced to get themodules of their children from the school and deliver the sameafter completing the learning tasks. These scenarios brought many
challenges to the indigenous parents who are not well educated,
and therefore, equipped, to assist the educational demands andrequirements of their children. While they are battling on how tosustain the daily economic needs of their families, they are forced
to spend time assisting their children in facing the educational
struggles brought about by the pandemic. This paper discusses thechallenges and aspiration of the indigenous parents in Davao delSur. Forced by the circumstance and driven by their fervent hopethat their children will inish schooling to be able to help them beemancipated from poverty; these parents have managed to double
their time and effort to assist their children in ways they can, sothat their children feel their presence and moral support in thesechallenging times. Though many of them had trouble in guiding
and teaching their children, while at the same time attended to theeconomic survival of the family, they are still grateful because insome ways, and are also learning while guiding their children in161

their modular classes. However, these indigenous parents hopethat schools will look for mechanisms to enable teachers to bephysically present and to teach their children face to faceaccompanied with the proper health protocols. In addition, they
hope that things will go back to normal or the usual way ofeducating their children because they feel that their children learn
best when there is physical presence of teachers in terms ofdelivering the modality of teaching and classroom instructions. Is
this the new normal that they are really aspiring for? Or shall they
be more concerned with the coming of a post-normal?

Introduction
Even before Covid-19 hit the country and practicallychanged people’s normal way of life and education ofchildren, indigenous education was already ineffective formany years in the Philippines. There were many attempts torevise the curriculum to make it more culturally signi icant
and responsive to the indigenous people, but these changes
are still anchored on an attempt by the elite and thepowerful to continue the normal way, meaning, to retain thestatus quo in the way educational institutions are being
administered which includes the curriculum
implementation in general. According to Maboloc (2020),
there is still domination in the education of the country
because the educational system is still elitist, and it isprimarily geared towards the satisfaction of the demands ofthe globalized economy. Thus, there is not much that haschanged in the educational system in the country.
Since Covid-19 struck the world and the Philippines inparticular, many things have changed. In the education
sector, schools were forced to go on-line, modular or a
combination of both, to be able to continue the education ofchildren. will this change in curriculum implementation
result in change of the aim and purpose of education in the
country? This has yet to be seen. What is obvious now isthat in whatever mode of curriculum implementation that
the Philippine educational system would adopt, theindigenous peoples are always left behind. Will there be
new normal for them? Or shall they be more concerned ofthe post-normal in education?
Maboloc (2020) argues that the term new normal is kindof linguistic tool used by the government and policy makers
to condition the people that things will never be the same as
they were before; thus, a new standard of life and of doing
things will have to be followed. Although Maboloc says thatthe new normal will require people to let go of certain
comforts, this might be applicable to those who have been
living in the comforts and luxuries of their status andpositions in society. But for the IPs who have been battlingwith poverty, discrimination, and the gradual loss of theirlands to corporate actors, their life has been and is still inmisery. Maboloc (2020) further says that what might beneeded is a paradigm shift in the post-normal way of life.
Speaking of the possibility that powerful interests might
still dictate the way things must be done in our life and evenin the educational system, Maboloc hopes that a “postpandemic world must consider not only the comfort zones ofpeople but must also attempt to alter the unjust systems andunfair power relations” (Maboloc, 2020:439).

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Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

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With this philosophical frame in mind and with theactual scenarios in the lives of the indigenous peoples in the
ground, this paper focuses on the experiences and strugglesof the Blaan parents in Davao del Sur vis-à-vis the on-line
and modular mode of education of their children.
Furthermore, this paper will also discuss the aspirations
and hopes of the B’laan parents about the education of theirchildren. Finally, using critical analysis, this paper will end
with the discussion on what should be or what might be thethings that the B’laans hope and dream for in the educationof their children.
One of the directives of the Republic Act 8317 or the
Indigenous Peoples Rights Acts (IPRA) is to provide an
inclusive system of education appropriate to the needs ofthe youths of Indigenous Cultural Communities (ICCs)/
Indigenous Peoples (IPs). Unfortunately, policy crafting andimplementation relative to these commitments are
painstaking. Despite the presence of IPRA law, the policies
and regulations that shall cover the indigenous peoples’
education were not given direct and fast action for an
operative implementation. It is the hope of the IP parents tofurther the education and learning of their children.
However, apart from the challenging and demandingtransition brought about by the pandemic, these IP students
also continuously experience discrimination from teachers,
students, and schools due to ethnicity (Bayod, 2019).
Discrimination from peers and classmates were also
condoned and not reprimanded. School systems’ policy likemandatory wearing uniform and shoes becomes additionalburden to the inancial capacity of most indigenous families.
Indigenous students were also labelled slow learners due todifferences in the language and context learned in thecommunity compared to the context learned and taught in
the formal school (Andrada, Magalona & Evangelista, 2020).
As such, while IP parents have already been burdened by
the sudden shift in the modality of learning, there are otherfactors which at some point demotivate them to send theirchildren to school.
This study aims to gather irsthand data from the B’laanparents about the modular and on-line education that the
DepEd and other schools have been implementing for theeducation of their children. Primary data are important in
the evaluation as well as crafting of education programs andpolicies during the pandemic and even in the postpandemic education of the IPs. We want to help thegovernment and Department of Education (DepEd) in theirquest to provide quality and meaningful learning to thestudents. While there are different initiatives as well as
budget being released by the government to help the
Department of Education to procure the needed materials
to continue the education of children, we would like toknow how these initiatives and budgets have been
implemented in the far- lung areas, especially in theindigenous communities. In fact, some schools have beenrequiring their parents to give monthly dues or contribution
for the purchase of bond papers and ink. Some teachers
have also been soliciting for these materials in their
Facebook accounts (Bayod, & Bayod, 2020).

To be able to gather the important data, we asked
twelve B’laan parents who consented to participate in the
study, the following questions:
1) What is your assessment or evaluation on the Alternative
Delivery Mode (ADM) of education that DepEd and otherschools have implemented?
2) While the system is still on-going, what is yoursuggestion and hope that the DepEd and other schools willconsider doing?
3) What is you dream for the future of your children?
Methods
We used individual interviews with our participants. Fourof the 12 participants were interviewed on-line. Eightparticipants were interviewed face-to-face by our coresearcher in this study who is assigned in the school of the
far- lung area where most of the population are B’laans. Theinterviews were then transcribed, and then analyzed using
thematic and content analysis which are the most used data
analysis technique in qualitative study. Furthermore, we
also used critical analysis to argue on our claim that theBl’aans or the IPs in general should not be concerned withthe coming of the new normal with its imposition of new
standards and rules which might be detrimental to theirstruggle for self-autonomy in their ancestral domain. Rather
than hoping for the new normal or to go back to the usual
way of education of their children, indigenous peoples
should be more hopeful for the coming of the post-normal
world where justice, equality and recognition of humandecency and dignity is not based on people’s status andpositions of society. Readers may request for the original
language transcripts of the quotations presented here.
Results and Discussion
B’laan parents’ take on modular classes
It is now four to ive months since the start of the modular
classes that Department of Education (DepEd) has
implemented. Since parents have much bigger role as
regards to this new mode of learning (Bayod, C. & Bayod, R.,2020), we asked them about their assessment on themodular classes. Many of them shared their positive andnegative assessment of the way the modular classes arebeing implemented in their locality. As to the negative
assessment, they shared that there is dif iculty inunderstanding the lesson on the part of their children and to
the parents. They also said that in modular classes, there isinsuf icient learning because of so many reasons. Lastly, theyshared that modular classes had resulted in disruption of
their daily works. However, on the positive side, they also
shared that they have also learned something while guiding
their children to learn the lessons.
Dif iculty in understanding the lesson. In the study of
Bayod & Morante (2020) on the fear and hope of B’laanlearners in Davao del Sur as regards to education in the newnormal, they found out that one of the fears of the B’laanlearners is on how they can really learn considering that
there will be no teachers to teach them physically. B’laanlearners shared that they had trouble in understandingEubios Journal of Asian and International Bioethics 31(3) (March 2021)

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lesson during face-to-face classes when there are teachers
who can really teach them, how much more if there are no
more teachers who will physically teach and guide them.
This fear was con irmed by B’laan parents in this present
study. Expressing her struggle every time her children ask
her about their lessons, a B’laan mother who has threechildren studying in the elementary level had these words:“It is very dif icult because there are lots of lessons I cannot
understand. I also cannot understand my answers. It is better
if they can see their teachers face to face because we can ask
them to give examples. It is different if there is no teacher, I
really cannot understand…their lesson is for high school and I
haven’t even reached high school.”This was supported by another parent in saying: “To behonest, I really have dif iculty with the modules because I amunschooled”. This was also con irmed by another parent
when she says: “It is very dif icult because I lack education. It
is all right if I am well educated and this has become myproblem. The modules piled up, because when I tell mychildren there are new modules, I have another child who
cannot sustain reading”.
Most of the parents found the lessons in the modules
dif icult to understand because they are less educated. Manyof them only reached elementary level in their education.
Another parent says: “there are some topics that we reallycannot understand, because we are not that educated. In fact,
I am only an elementary graduate. My children have
dif iculty, and they really cannot understand and I cannot
personally teach them.”
They shared that the lessons in the module were
dif icult to understand not only for them but also for theirchildren. A B’laan father says: “It is really very dif icult, I
cannot understand. I am only up to Grade 4, so how can I
teach my child. I cannot understand English. Every time mychild asks me questions; I cannot give an answer. Even a
graduating student inds it dif icult.”
The dif iculty in understanding the lessons is
exacerbated since modules are written in English andexamples are detached from the culture and daily life
experiences of the B’laans. While in some Divisions, they
have one subject for grades 1-3 which is called a MotherTongue Based -Multi-Lingual Education (MTB-MLE), not all
schools have faithfully implemented this since they lackteachers who know the local language and thus, they are notcapable of teaching. In the higher grades, there is no more
MTB-MLE subject. Hence, the IPs are forced to follow thestandardized curriculum which is patterned from the Westand imposed by elite leaders in the education sector.
Western notions of education were regarded as superior
that is why they have been implemented with presumed
supremacy while indigenous epistemology and belief
systems were considered by Western educators to bede icient (Campeau & Makokis, 2003).
The situation of the IPs regarding their education isre lective of the reality of social, political, and economic
exclusion in the county (Maboloc, 2020). While there had
been many curricular reforms in the country’s educational
system, miseducation of Filipinos according to Constantino

163(1996) persists because education is still about speaking,thinking and writing well in English. The recently legalized
Republic Act 10533 or Enhanced Basic Education Act of2013 includes a basic education curriculum that is inclusiveand developmentally appropriate, relevant, culturesensitive, contextualized, and lexible (DepEd Order No. 43,
2. 2013). The act mandates and allows schools to localize
and indigenize the curricula based on their educational andsocial context within the national competencies required informal and non-formal education for all learners regardlessof socioeconomic and cultural backgrounds. While there
were policies intended solely for the IP students to direct
them in their much speci ied and tailored curriculum toaddress their educational requirements which may in turnfacilitate learning and comprehension among them, they are
not yet fully operational in many schools. In addition, thisinitiative was not wholeheartedly embraced by the IPs
because they were not consulted in the crafting of thesepolicies and programs. These policies and programs havebeen made by elite leaders. While some of them might havestudied the culture and traditions of the IPs, they are not IP
themselves, and therefore they cannot totally grasp the realneeds and aspirations of the IPs. However, educational
leaders who have initiated these programs and policies may
have had the intention of providing relevant and meaningfuleducation for the IPs.
Insuf icient learning. B’laan parents in this study said thatthe on-line and/or modular classes resulted in insuf icientlearning among their children. They have pointed out manyreasons like the lessons are dif icult and that they do nothave the educated persons to teach and guide their children,and they do not have gadgets to surf the internet tosupplement their modules. Aside from the gadgets, they do
not have access to the internet because of their location. In
addition, some of them said that since the modules containthe answer key, they were sometimes tempted to copy theanswer key and do not labor hard to read and study thelessons. Thus, there is insuf iciency in learning. For instance,
one parent says: “An answer key is provided at the back, so
we just copy not even knowing what is meant by what is
written. That’s why whoever understands should be the one toread because I don’t know how to translate it, however, no
one understands because the lesson is dif icult.” B’laanparents really wanted their children to learn. If they canhelp to let them understand the lessons, they will really doit. They got disappointed when their children just copied
the answer key and let other people answer the modules
too. Another parent says: “What makes modular
discouraging is because some let other people answer it, andso they will not learn at all. They just submit for complianceto the teacher, but the question is, have they learned
something?”
Speaking of the modular classes and the lack of gadgetthat will help their children in answering the lessons, aparent shares her sentiment: “For me, module is a bitinconvenient to the children because their learning is notcomplete on that. My senior high school student has thisEubios Journal of Asian and International Bioethics 31(3) (March 2021)

problem because there are times their teacher tells them toget the module in Digos, and to think it is very far from
Matanao…now what makes it even more dif icult is that mychild doesn’t have a cellphone to be used for research in her
lessons because there are instructions that need search theinternet.”
Another parent, a B’laan father shares his observation as
regards to the modular classes: “The modules nowadays areokey because children will just work on it at home, and they
are safe from covid. Our point is that it is dif icult tounderstand especially if there is no internet connection at
home, so they really need to drop a peso in a peso net. They
cannot go online because they have no money. Previously as
students, they needed only their allowance. I don’t have myown wi i, so I drop peso coins in a peso net. I am spending for
wi i”.
The claims of the B’laan parents that in modular classes,
there is insuf iciency in learning because the lessons are
dif icult and that they do not have the right persons andthings to assist their children in learning are valid. Even in
face-to face classes, most have low self-con idence to takeadvantage of the different classroom activities and learning
tasks. They feel inferior in so many ways in front of theirteachers and their classmates who are coming from thelowland. Most of them experienced bullying in schools
without protection from those who are supposed to protect
them such as school and community leaders (Bayod, 2019).
As enunciated in their paper, Galindo, Reginio, Liguid,
Sancon and Advincula (2018) believed that inancial
capacity, marginalization, and fear of being discriminated,
oftentimes verbally, hinder IPs from achieving their fullacademic potential. These factors add up to the IP parents’
dif iculty in coping with their feeling of inadequacy with themodular classes. While a lot of their children may have theintellectual capacities to understand the lessons andcomplete the given learning tasks, there is fear of being
rejected and not attended to, and there is inancial
constraint. In addition, they experienced confusion as to theright person to approach for assistance. In the case of theirparents, they also experienced the same. Aside from the factthat they do not have the intellectual capacities to help theirchildren in their modular classes, their feeling of ineptitude
has exacerbated their experiences and conviction that inmodular classes, there is insuf iciency in learning because
as parents, they cannot assist and guide their children in
their academic journey.

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Disruption of their daily works. Another theme thatemerged from the narrative of the participants is that themodular classes have resulted in the disruptions of daily
works. A B’laan father said: “I ind module dif icult, and it
disrupts my work. Instead of me going to the farm, I could nolonger go because I study to help my child and majority of themodules I do not know how to answer even if it is forelementary level. I ind it really dif icult. It also delays work”.
Talking on how the modular classes disrupted their daily
works in the farm, here are the words of the the B’laan
couple: “We both agreed that if we cannot understand the

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module, we might as well have the option to return it even if
there are no answers. I would prefer that the teacher shall be
the one to teach because we cannot sustain, and we could nolonger work in our farm and we have no food to eat because
we only rely on our farm income for living. I could no longer
help my husband because I always look after the children. If
we just let them be, they cannot absorb it, they will just keepon playing. I feel so worried. There was even a time that they
really cannot understand, I returned it. Our daughter
eventually gave up.”
Another B’laan parent shares her struggles as regards tothe system surrounding the modular classes: “What istiresome about this modular is in getting a copy andsubmission. I have two students and it is dif icult for me. It is a
lot better if in a week I only need to get module at least once.
But we get it by section, so parents are burdened. Other
parents have four students, so they need to travel four times
also. The fare is Php100 back and forth, so we spend Php400
in just one week.”
For the IPs whose daily work is in the farm andsometimes the farms are located a bit far from their houses,
it is dif icult to suspend works in the farm to be able toguide their children in modular classes. While they arewilling to sacri ice a day or two in their farm works to bewith their children in their on-line or modular classes, theyalso cannot maximize their presence in terms of helping
their children because they are not knowledgeable enoughof the lessons which are mostly written in English. In
addition, long disruption of their works in the farm will
have signi icant impact on their economic survival. Thus,
the modular classes of their children which requires theirattention, help and supervision has resulted in disruption of
their farm work. Because they would like that their children
continue to study, some of them have devised a strategy totake turns in attending to the needs of their children while
they are on modular classes so that their partner can still
continue with the farm work which is the source of theirlivelihood.
Since most of the Filipinos, and especially, the IPs havestrong family ties, the presence of the members of thefamily, especially, the parents, have signi icant contribution
to the educational journey of the children. Based on the
Sand ield Day Nursery (2020), children learn best when
they have opportunities to interact with their environment
particularly with their parents who are very important totheir children's external in luence. A child learns best when
he or she gets full support by the parents. In the case of theIP parents, aside from not being able to assist their children
full time due to farm work, they are also struggling in termsof understanding the content of the modules. They are torn
between priorities that are both important in the aspect of
their children’s’ lives. Along with Piaget’s theory was thetheory on mentoring by Lyv Vygotsky from the research
conducted by Mcleod (2028), which cited that children’sinteraction with their family members in the community is
so essential for their learning and development since theirirst learning takes place from them as internal factor andsociety as the external environment. This statement proves

that the support of parents on their children’s schooloutcomes is expected. It is undeniable that the support isthere, however, IP parents are limited in teaching theirchildren because they lack knowledge on how to deal withthe lessons presented in the modules at the same time, they
are struggling with managing their time and priorities
which are both important to them. The study of CuarteroEnteria & Tagyam (2020) concluded that despite theireducational background and economic status, IP parents areaware of their role as parents, but they are not fully
responsive on the responsibility behind shaping the futureof their children. IP parents have faced dilemmas in terms ofpriorities, whereby, they want to fully support the academic
performance of their children, but they also need to exert
more effort for their living and survival.

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Learned something while guiding their children. On thepositive note, some of the B’laan parents shared that despite
a lot of struggles and dif iculties, they discovered something
positive - they learned together with their children in themodular classes. This is captured by the words of a B’laanmother who said that at irst she really found it dif icult
considering that she is just an elementary graduate but lateron, despite disruption of works and lots of struggle she isalso happy because she learned something: “I ind it dif icult,and it also disrupts my work, but I am happy because I learnsomething. As I am involved, I learn. However, in all themodules, if I do not know I will have to skip and then I let myother child explain to the younger sibling. I honestly learn
although I am up to elementary level only, I feel I can reachsecond year level, but I still ind dif iculty answering. I evenind it funny because in my mind I am using the dialect andthen I realized I need to use Tagalog or English language inanswering, I ind that dif icult that’s why I call on for help
from our neighbor on how to translate into Tagalog or
English of a particular term.”
This was also supported by a parent when she narrates
here experiences in guiding her child in the modular
classes: “What I found out about module is that at irst I
really ind it dif icult but later as we approached on our
second week of involvement, we are also learning as we read
together with our children, they also follow through what weare reading. I also commit mistake at times in the answers.
Sometimes my child tells me, Ma, our answer is not correct.
We both learn. I read and my child follows through what I am
reading that is why sometimes we tend to shout with eachother because we are actually reading. For Filipino subject wehave no problem but with English subject, that is what makes
it dif icult for me sometimes because my child is not a luent
reader because no matter how many times I keep repeating, it
becomes a struggle but eventually as we are doing it often, my
child improves her reading in English.”Despite dif iculty, the modular classes allowed theparents to learn. Maybe, if they have the choice, they willcontinue to study and learn the lesson in the module but
they are caught up with daily farm works for economic
survival to the point that most of them said that themodular classes have resulted in the disruption of theirffEubios Journal of Asian and International Bioethics 31(3) (March 2021)

165

works. But should they be given the chance to study and notworry on their daily economic survival, some of them mightenroll in modular classes, too. When IPs are educated, theirmindset and worldview will also be broadened. However, if
the education they receive is not culture sensitive, thismight have negative effect to their overall cultural survival.
During this time of crisis, we believe that there is much tolearn from the indigenous communities. Indigenous
knowledge about nature and science generally differs fromthe traditional and dominant Western modern view ofscience in research and technical applications (Nakashima& Roué 2002; Iaccarino 2003; Mazzocchi 2006). It provides
an alternative perspective on nature and human in nature
on its own right (Mur in 1994; Ogawa 1995) and therefore
becomes authentic to persons having an indigenous
background. It is also interesting that similar ideas to the
local wisdom of indigenous science exist in Eastern spiritual
thinking and alternative Western thinking. Such ideas arerel evant to inte rcul t u ral and in tergenerat io nal
understanding and respect (Brayboy & Maughan 2009;
Hatcher et al. 2009; de Beer &Whitlock 2009).
The post normal world might also be characterized by akind of atmosphere where the indigenous peoples might begiven the space and opportunity to share their lives andteach and the mainstream community. According to
Hiwasaki et al. (2015), connecting local-indigenous
knowledge with science-based knowledge has helped
others in dealing with changing con licts and disasters.
More importantly, inclusive integration of knowledge serves
a vital part in the transmission and continuation ofindigenous knowledge to the generations to come. The IPs
knowledge and practices should be acknowledged as
integral to crafting of development agendas. The
mainstream can also learn from their traditional methods
which are still very useful in today’s highly technologicalenvironment. A culture of sharing of skills, knowledge andpractices must be promoted in a post normal world. In thisculture of sharing and dialogue, IP gurus, Shamans, Baylans,
elders and their leaders may educate the mainstream
population because they have so much to offer for the
betterment of this world. This should be the characteristicof a post normal world. As discussed by Cuaton & Su (2020),
non-indigenous peoples, local communities, and scholars
can bene it from the local indigenous knowledge andpractices of indigenous peoples. One of the core elements ofthe concept lies in the continuity and succession of suchknowledge and practice that evolves over time, acquired
through years of experiences of local people and passed onfrom generation to generation (Sin & Mansson, 2017).
B’laan parents’ suggestions to DepEd on modular
classesB’laan parents acknowledged that modular classes willcontinue to be implemented by the DepEd for this year but
they have suggestions for the DepEd and the schools to
consider going back to face-to-face classes even once a weekor simply having by batch of students, then if modular classes
will really be the option, they have suggestion that modules

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should be complete with all examples in printed materials
and improve the system of module distribution.
For the B’laan parents, since they cannot suf iciently
guide and teach their children during modular classes, they
hope that the DepEd and the schools will consider
conducting face-to-face classes even once a week and with asmaller number of students by batch. For example, one
B’laan parent shares: “Because module is dif icult, I shouldsuggest that, if possible teachers will get at least three
students in a single day and the next day another batch of
students so they can just come and visit the homes or schoolsof these students. Module is ine if a child knows how to readbut for those who are non-readers, they will ind it dif icult
and with the parents who are non-readers.”
This is also supported by another B’laan parent when
she says: “It is hoped that teachers will teach face to face atleast once a week. It is hoped that teachers will come back inteaching the students because we cannot do it.”
Another parent also shares: “my request is to go back to
the ways on face-to-face teaching with our children. If they
allow our children to go to school, I will allow my child tocome because I cannot do the task. I am ine with every
morning classes only. There are times I am confused. Our
problem is the signal while we do internet search. We borrowand share cellphones …”
B’laan parents have a suggestion that teachers mayschedule face-to-face classes to the students even once aweek and with smaller number of students so that they
their children will really learn. This is because they cannot
fully guide their children during modular classes. These
parents really wanted to be involved with the schooling of
their children that is why they have humble suggestion to
the school authorities. The mere fact that they acknowledge
their limitations in terms of fully assisting their children in
their academic journey and their suggestion is an indicationof their desire to be involved with the education of theirchildren. According to Greenman et al. (2011), parental
academic involvement has a strong effect on children living
in disadvantaged localities. Parental interest in theiroffspring’s studies may in fact have shielding effects on
academic achievement brought about by deprivation. It
camou lages the effect of a range of risk involving factors,
low socio-economic position, psychological andphysiological stress, negative emotions. With these thoughts
and ideals, IP parents need to get by with the challenges
brought about by the pandemic in terms of educational setup. It is true that they are limited in terms of assisting theirchildren in their academic endeavors but perhaps given theproper intervention, they will be encouraged and motivated
to cope with the educational and academic transitions of the
new normal.
Since most of them do not have gadgets such as
cellphone and laptops and do not have internet signal/
connection in their houses, they suggest that if modular
classes will continue, the modules must be complete with all
examples and in printed form so that they will not have to
face another problem of searching the net and that means,going down the towns and internet cafes for the internet

signal. This was captured by the empathic sharing of one
parent: “Is it true that ink is used for printing the modules?
They should be the one to provide for that instead of asking
an amount from us to buy bond paper every month. It is like
this, in our case, our income is every four months so if we give
our monthly share, where do we get that money? that is thereality. One rim costs Php 200. DepEd should provide ink,
bond paper and other needs of the children in school. My
suggestion is that the modules should be complete instead ofasking us to print as we need it so our children are again
compelled to go to internet cafes. The face to face andmodular way of teaching are really very different. For face-toface classes teachers will really explain to the students about
the lesson, right? But on the module, we learn and understandby ourselves. I ind it hard to read especially if texts are small
letters.”
This parent is not only talking about the complete
module but also the free materials and that they should not
be obliged to pay or contribute something for the bondpapers. This is something that the DepEd should address.
They must make sure how to minimize the modules without
jeopardizing important learning competencies so that they
do not have to spend huge amount of money for the printingof these materials. Although the public-school system in thePhilippines offers free tuition until high school, many publicschools have shown poor outcomes in national andinternational assessments compared to private schools(Yap, 2011). IP parents are concerned about contents of themodule to facilitate learning and about the cost it incurs inprinting the modules. It is a fact that extreme poverty limits
families’ choices in terms of sending their children toschool. Many low-income families enroll their children in
public schools, despite its academic reputation, forsubsidized education (Maligalig, et al. 2010).
Improve the system of module distribution. B’laanparents, especially those living in the mountains haveanother suggestion, and that is, the improvement of thesystem of the module distribution. While it is alright forthem that they will be the one to get the modules and returnthe modules, they suggested that an improvement in thesystem should be addressed like only once a week
distribution and submission of modules and then all themodules from Kinder to Grades 12 should be given all at
once. This concern is captured by the sharing of this parent:“What is tiresome about this modular is getting a copy andsubmission. I have two students and it is dif icult for me. It is a
lot better if in a week I only need to get module at least once.
But we get it by section, so parents are burdened. The fare is
Php100 back and forth, so we spend Php400 in just one week.
My suggestion is that if only we can get the modules one time
per grade level. One teacher in fact, does not come to school if
it is not his schedule of duty. So, we depend on his schedule. I
hope they ind ways so we can get modules all at once.”
They are suggesting that if it is okay, the school will makea system that complete modules will be given all at once. In
addition, since the IPs are practicing a communal way of life
(Bayod, 2018), it’s not an issue for them if some parents will

get the modules of another child. In fact, they are suggestingthat the school will accept a kind of community
representative who will get all the modules for theirchildren for the week and then submit these modules also
the following week.
Considering that some students come from families that
depend on farming and small-scale businesses, issues ofschool fees are likely to emerge as limiting factors for thesechildren to go back to school. Families are unable to conduct
their businesses normally due to COVID-19 and theirinancial base is being depleted every day. This is being seen
as a potential threat to their capacity to pay school fees fortheir children. While in developed countries with readily
available resources, the pandemic has presented
opportunities for transitioning to using eLearning platforms
in schools and higher learning institutions (Toquero, 2020),
for many developing countries whose educational sectors
are suffering from inadequate teaching and learningmaterials, lack of e-learning facilities due to inadequate
funding, effects of COVID-19 have so far had a negative
impact on learners (Sintema, 2020). This is true mostespecially to IP parents. Their utmost priority is how to getby with their basic needs, but they have the aspiration ofsending their kids to school and yet, with limited support,
they might be forced to give up education. It is more on
survival than continuing to embrace the modular lesson
which to them is an added burden inancially, physically, andintellectually.

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B’laan parents’ dreams for the future of their children
Despite a lot of challenges and dif iculties, B’laan parents
continue to dream that their children will continue to study
and inish their schooling because for them the education of
their children is one of the means that they will beemancipated from poverty. Because of this they dream that
the Covid-19 will disappear so they can go back to thenormal way of life.
All of them wanted that their children to continue tostudy. One parent shares her irm decision to let her
children continue to study in the midst of Covid-19 threat:“Amidst Covid, amidst dif iculty, and amidst the trials we
encountered, I want my children to pursue their education.
There are others who started to give up and stop learning.
Others would say they cannot learn anything because it is theparents, sisters, relatives who are teachers. Some would evensay they will not learn anything from it. But in my case, I do
not answer my child’s module because that is their
responsibility. I don’t discourage them, instead I encouragethem that amidst the dif iculty, they will have to strive hard. I
thought of time and effort lost if they stop schooling because I
believe it will not be like this all the time.”
Another parent also shares: “My dream for my children isfor them to continue learning. Hoping that the teachers will
also not give up.”
Despite all odds, B’laan parents really value theeducation of their children and that they really wanted that
their children to continue to study. While they havesuggestions for the DepEd to consider, they are still willing

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167

to follow the decision of the DepEd in order that theirchildren continue to be admitted in school. While this result
supports Vygotsky’s socio-cultural theory that teachers andparents’ partnership should go hand in hand for closemonitoring of the students’ educational accomplishments, aword of caution should be taken into consideration here
because the vulnerable and uneducated IPs are an easy preyfor exploitation and control by the powerful. Thus,
capability building for IP parents is still necessary not only
to further enhance their awareness on their important role
to support and provide guidance to their children(Cuartero-Enteria & Tagyam, 2020) but also on their crucialrole to monitor the kind of education given to their children
by the mainstream educational institutions. These IP
parents are concerned with the educational welfare of theirchildren and that while they trust the school to administerand facilitate the educational processes for their children,
they also need to be vigilant to the different inputs imposedand given by the school to the curious and docile minds oftheir children.
The main reason that B’laan parents wanted theirchildren to continue their study is because they have thehope that their children will soon inish their studies andhave stable job so that they can help their families. A very
supportive B’laan father has these words to say: “my dreamis for my children to inish their studies and the course theywish to pursue. They should continue their studies and not tohurry and marry yet so that they will not have a hard-up life
and they can help us in the future.”
In a similar way, a supportive mother also shares her
dream for their children: “My dream for my children is forthem to inish their studies, and that they will not be like us inthis similar situation, I want them to really inish school….”
Another parent also shares, “I only have one dream for mychildren, for them to inish their studies. That is their key toget away from poverty.”
The B’laan parents are willing to really sacri ice manythings for the sake of the education of their children. They
really wanted that their children to inish their studies andachieve their desired course/dream in life. They also hopethat they will not forget them if they have already stable jobin the future. The IP parents are motivated by perseverance
which refers to the acceptance of dif iculties and challenges
in life. They were able to develop coping mechanisms indealing with the struggles. They saw education as anopportunity for growth and personal enhancement. The
outlook of the participants to acquire education paved way
to a better life for themselves and for their family. The
struggles faced by the participants made them inferior atirst, yet it catalyzed their determination to achieve theirgoal (Galindo et al., 2013). The result of this study showed
how IP parents had given importance to education, for they
believe that it will serve as their deliverance from theconstant discrimination against them. They believe thatgetting a diploma will liberate them from extreme poverty
and this shall also pave the way to helping others to theirfellow IPs as a means of giving back once they become
successful.

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For the beautiful future of their children, B’laan parents
also hope that Covid-19 will soon disappear so that things
will go back to normal especially as regards the education of
their children. This was captured by one parent when shesays: “My dream for my children is for them to have acontinuous education. Second this pandemic shall come topass so that they can go back to face-to-face classes. Just as
we are, we hope to have healthy life. It is my dream that mykids sincerely go to school and keep them away from sickness
because life in the mountain is dif icult.”
Another parent also shares his hope that the Covid-19
will soon disappear: “it is my hope and prayer that Covid
shall come to an end so my kids can go back to face to faceclasses and we no longer worry about our child while inschool because we are in the mountain most of the timeattending to our farm.”
It is clear that the B’laan parents hope that the Covid-19
will disappear, and things will go back to normal especiallyin relation to the education of their children. But what is thenormal course of education for their children that they arehoping for? Does this mean that they are bound to accept
the fact that there will be no genuine IP education in the
country? Are they content to accept that education in the
country is still elitist and that this will have signi icant
impact to the values and belief systems of their children in
the future? Are they prepared for these consequences tohappen?
Findings in the study of Garcia and de Guzman (2020)
point to low-income Filipino parents’ conceptualizations ofinvolvement to support their children’s schooling and an
indication regarding their desire to support their children’s
success despite the many challenges they face given theircircumstances. Recent linkages with the Department of
Education have led to con lict over control of the school,
leading the tribe to fear the loss of their identity. Other
linkages are currently being established for the survival andfurther development of the school. Administrators andeducators can capitalize upon their notions and desires byhelping their children develop strategies that it withinparents’ beliefs. By starting with these culturally informed
categories of involvement, strategies may be more relevant
and meaningful for parents in this speci ic context (Garcia &de Guzman, 2020).
Conclusion
It is undeniable that indigenous peoples (IPs) belong to themarginalized group for their unique ways of living,practices, beliefs, and physical characteristics. While thesegroup of people live their lives in the hinterlands, the IP
parents, particularly the B’laans of Davao del Sur havehopes and dreams for their children to be educated. They
believe that education liberates them from extreme poverty
so they may live a life free from subjugation anddiscrimination. With the outbreak of the Covid19 pandemic,
there are among the marginalized group that are largely
affected most especially in sending their children to school.
While the IPs are willing to embrace the new normal where
there are new protocols, they are also subjected to the new
apparatus of control by the powerful on the powerless inthe aspect of educating their children. It might be good thatthey will brace and hope for the post-normal where there istrue recognition of their unique identity and culture andequality of opportunity in all aspects in the education of
their children. The post-normal situation may also mean,
genuine participation of the IPs in the crafting of programs
and policies affecting their life and identity as well as thevery source of their life and identity – their ancestral
domains. Hopefully, the COVID-19 crisis will evoke a kind of
metanoia to the leaders and policy makers of this country tocome up with radical decision that will cater to the interestsof all, especially the marginalized IPs.
Since, they have been ignored and abused, many of them
become docile. That is why instead of talking about post
normal, they are just content of the new normal. Hence, they
have a humble suggestion to the DepEd to go face to faceclasses even if there will be modi ication of this scheme. In
their minds, the modi ication might be once a week of only
half day. But surely, the IPs will be very happy if there will
be a dawning of the post- normal. It will happen if theleaders of this country will faithfully adhere to the 1987
Philippine Constitution, Article XIV Section 17 which statesthat the State shall recognize, respect, and protect the rights
of indigenous cultural communities to preserve and develop
their cultures, traditions, and institutions. It shall consider
these rights in the formulation of national plans and policies
which was reinforced by the IPRA law in the 1987
Constitution’s mandate that the State should craft a policy“to recognize and promote the rights of indigenous peoples
within the framework of national unity and development”
and “to protect the rights of indigenous cultural communities
to their ancestral lands to ensure their economic, social andcultural well-being” (Asian Development Bank 2002: 13).
The Department of Education could also provide moreautonomy to its regional of ices to collaborate withindigenous groups in curriculum formulation. At present,
curriculum content and formulation are too centralized. The
IPs hope is that these groups of people will genuinely
recognize their present plight so that they will intervene toprovide what they currently need in this time of pandemic.
References
Abejuela III, R. B. (2017). Indigenous Education in the Philippines.
Andrada, M. D., Magalona, J. S., & Evangelista, L. T. (2020). Education andEthnicity: A Phenomenology from the Lens of the Indigenous Peoples ofCamarines Sur. Asia Paci ic Higher Education Research Journal (APHERJ),
7(1).
Asian Development Bank. (2002). Ethnic Minorities and Poverty Reduction.
Asian Development Bank: Philippines. 103 pages.
Bayod, R. (2018). The Future of the Environment and the Indigenous
Peoples of the Philippines under the Duterte Administration, Social
Ethics Society Journal of Applied Philosophy Special Issue, December
2018, pp.229-253
Bayod, R. (2019). Developing an indigenous ethics: On Recognition andSocial Justice, Eubios Journal of Asian and International Bioethics, 29(1):xxxx.
Bayod, R. & Morante, J. (2020). Fears and Hopes of Indigenous Students inSouthern Mindanao During Covid-19 Pandemic, Eubios Journal of Asianand International Bioethics 30(6) (August 2020)
Bayod, C. & Bayod, R. (2020). Couple educators’ mission during COVID-19
pandemic: ensuring a meaningful and relevant learning for students

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

f

f

f

f

f

f

f

while staying at home, Eubios Journal of Asian and International
Bioethics 30(6) (August 2020)
Bayod, R. & Bayod, C. (2020). Laying the groundworks for education ofchildren in the new normal: The case of DepEd Southern Mindanao,
Eubios Journal of Asian and International Bioethics 30(8) (October 2020)
Brayboy, B. M. J., & Maughan, E. (2009). Indigenous knowledges and thestory of the bean. Harvard Educational Review, 79(1), 1–20.
Campeau, P. & Makokis, J. (2003). “Indigenous Distance Education”, Cultural
Survival Quarterly Magazine. Retrieved December 2020 https://www.culturalsurvival.org/ publications/cultural-survival-quarterly/
indigenous-distance-education
Constantino, R. (1966). The Miseducation of the Filipino, Malaya Books.
Cuartero-Enteria, O., & Tagyam, R. P. (2020). Parental Involvement in the
Education Development of Indigenous People in Selected Elementary
Schools in the Northern Part of Mindanao, Philippines. Asian Journal ofAdvanced Research and Reports, 16-27.
Cuaton, G. P., & Su, Y. (2020). Local-indigenous knowledge on disaster risk
reduction: Insights from the Mamanwa indigenous peoples in Basey,
Samar after Typhoon Haiyan in the Philippines. International Journal ofDisaster Risk Reduction, 48, 101596.
De Beer, J., & Whitlock, E. (2009). Indigenous knowledge in the life sciencesclassroom: put on your de bono hats! The American Biology Teacher, 71,
209–216.
DepEd Order No. 43, s. (2013) Implementing rules and regulations ofRepublic Act 10533 Otherwise Known as The Enhanced Basic Education
Act of 2013. Retrieved from https://www.deped. gov.ph/2013/09/24/
do-43-s-2013- implementing-rules-and-regulationsirr-of-republic-actno-10533-otherwise-known-as-the-enhanced-basiceducation-actof-2013/
Galindo, M.Q., Reginio, F., Liguid, E., Sancon, T.F., & Advincula, J. (2018).
Lived experiences of the Indigenous People in reaching their fullacademic potentials: Unveil their hopes, fears, and dreams. International
Journal of Education Research for Higher Learning 24 (1) ,25-41
https://ejournals.ph/article. php?id=13273.
Garcia, A. S., & de Guzman, M. R. T. (2020). The meanings and ways ofparental involvement among low-income Filipinos. Early Childhood
Research Quarterly, 53, 343-354.
Hatcher, A., Bartlett, C., Marshall, A., & Marshall, M. (2009). Two-eyedseeing in the classroom environment: concepts, approaches, andchallenges. Canadian Journal of Science Mathematics and Technology
Education, 9(3), 141–153.
Hiwasaki, L.,Luna, E., Syamsidik, S.R., Marçal, J.A. (2015). Local andindigenous knowledge on Climate-related hazards of coastal and small
Island communities in Southeast Asia, Climatic Change 128:35–56,
https://doi.org/10.1007/s10584-014- 1288-8.
Iaccarino, M. (2003). Science and culture. EMBO Reports (European
Molecular Biology Organization), 4, 220– 223.
Maboloc, C.R. (2020). New Normal or Post-Normal? PhilosophicalImplications of the Covid-19 Pandemic, Eubios Journal of Asian andInternational Bioethics 30(8) (October 2020)
Maboloc, C.R. (2020). Ethics in Contemporary Philippine Society. Davao City:
SMKC Publishing, 2020: pp.7-17.
Maligalig, D., Caoili-Rodriguez, R., Martinez, A., & Cuevas, S. (2010).
Education outcomes in the Philippines. Manila, Philippines: ADB.
Mazzocchi, F. (2006). Western science and traditional knowledge. EMBO
Reports (European Molecular Biology Organization), 7, 463–466
Mcleod SA. Lev Vygotsky (2018). Simply Psychology. Retrieved December
08, 2020 https://www.simplypsychology.or g/vygotsky.html
Mur in, B. (1994). African science, African and African American scientists
and the school science curriculum. School Science and Mathematics, 94,
96–103.
Nakashima, D.J., & Roué, M. (2002) Indigenous knowledge, peoples andsustainable practice. In Timmerman P (ed.) Encyclopedia of global
environmental change. 5: Social and economic dimensions of global
environmental change (pp 314–324). Chichester, UK: Wiley.
Ogawa, M. (1995). Science education in a multiscience perspective. Science
Education, 79, 583–593
Sand ield Day Nursery (2019). The importance of social interactions in thechild’s early years; from, https://www.sand ield-daynursery.co.uk/theimportance-of-socialinteractions-in-a-childs-early-years

169

Sintema, E. J., & Singogo, D. (2020). Educational Preparedness of the Home
Environment: A Technological Perspective Amidst Coronavirus(COVID-19) Outbreak. International Journal of Pedagogical Development
and Lifelong Learning, 2(1), ep2101. https://doi.org/10.30935/ijpdll/
9290
Sin,Y., Månsson, P. (2017). Integrating Local Knowledge into Disaster Risk
Reduction: Current Challenges and Recommendations for Future
Frameworks in the Asia Paci ic, Division of Risk Management andS o c i e t a l S a f e t y. L u n d U n i v e r s i t y. S w e d e n . h t t p s : / /p d f s . s e m a n t i c s c h o l a r. o r g / e 8 e 9 / 7 0 a d 7 2 0 d 6 5 6cc8ef0eda31a77ce05e0c681f.pdf
Toquero, C. M. (2020). Challenges and Opportunities for Higher Education
amid the COVID-19 Pandemic: The Philippine Context. PedagogicalResearch, 5(4), em0063. https://doi.org/10.29333/pr/ 7947
Yap, R. H. D. (2011). K to 12: The key to quality education. https://www.senate.gov.ph/publications/PBKto12TheKeytoQuality.pdf https://www.culturalsurvival.org/publications/ cultural-survival-quarterly/
indigenous-distance-education

Global ethics and the right touniversal access to COVID-19
vaccines- Christopher Ryan Maboloc, PhD
Ateneo de Davao University, the Philippines
Email: ryanmaboloc75@yahoo.com- Glio Joy Layos (Corresponding author)
Bukidnon State University, the Philippines
Email: gliojoylayos@gmail.com

Abstract
Universal access to Covid-19 vaccines is a global issue. By
universal access, we mean the need to equalize rather than
optimize the distribution of the vaccines. We argue that such is amatter that concerns social justice. Medical ethics presupposes thejustice principle, but we need to understand other ethicalquestions. We present the concept of entitlement and humanrights with respect to public goods of which vaccines are a part.
Liberalism puts as a matter of priority equal respect for the moral
worth of persons. The duty of the state, in this way, is to protect
the well-being of everyone. But given the uneven structures in theworld, the challenge is to ensure that the global poor will not beleft behind when it comes to the vaccines.

The coronavirus outbreak
There are hundreds of different coronaviruses in animals
and it is a rare occurrence that they infect humans. Over thelast two decades, there have been three highly pathogenic
and lethal human coronaviruses, namely SARS-CoV, MERSCoV and SARS-CoV-2. In February of 2003, Severe AcuteRespiratory Syndrome (SARS), a zoonotic virus transmitted
from civet cats to humans, was irst reported in Asia andquickly spread to 26 countries, resulting in more than 8,000
infections. The irst novel coronavirus of the 21st century
was contained shortly after China’s latest SARS outbreak on
May 18, 2004.
Almost a decade later, Middle East Respiratory
Syndrome (MERS), a zoonotic virus transmitted to humans
from dromedary camels, emerged and was irst reported in
Saudi Arabia in September 2012. Affecting 27 counties,
roughly 35% of reported patients with MERS-CoV have died.
The virus however does not seem to pass easily from person

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to person unless there is close contact. Today, the world
faces the third novel coronavirus of the century known as
SARS-CoV-2, which causes the coronavirus disease 2019
(Covid-19). The novel coronavirus came from China on
December 1, 2019 and was declared a pandemic by theWorld Health Organization (2021a) on March 11, 2020.
Pandemics undoubtedly create a global health crisis
resulting in social, political, and economic disruptions. The
challenge that the Covid-19 pandemic presents to publichealth is unprecedented. But af irmative actions to combat
pandemics are possible. Looking back, the predecessor of
Covid-19 was dramatically contained through the medical
intervention of vaccination. SARS was effectively containedin mid-2003 by isolating active cases and by means ofextensive contact tracing.
SARS and Covid-19 can spread by respiratory droplets.
Both have similar stability in the air and on various
surfaces. They also have similar at-risk groups and can leadto serious illnesses. The Covid-19 mortality rate is around 2
to 4 percent, while SARS was about 10 percent. The abilityof the virus to spread is also a key in understanding theirvirulence. The basic reproductive rate for SARS outbreak
was estimated to be between 2.0 and 3.0 in its early months
and soon reduced to 1.1 (Castillo-Chavez et al. 2004). To
date, an average of 2.5 basic reproductive rate for Covid-19
has been estimated (Wu et al. 2020).
Covid-19 is less deadly but is far more transmissible thanthe previous human coronaviruses. This means using asimilar strategy to SARS will not suf ice to control andcontain the virus especially because of the increasing rate oftransmission from asymptomatic people. The kinetics ofvirus shedding between human coronaviruses also differ
signi icantly. A study in Hong Kong (To et al. 2020)
con irmed by a study in China (Wang & Chang 2020),
suggests that Covid-19 obtained samples from swab tests
have high viral loads after hospital admission, while SARSCoV viral loads peak at 6-11 days after symptoms persist,allowing a full extra week to isolate cases before anytransmission.
The foregoing indings from the latest literature indicate
the urgency of vaccinations for people to be able to returnsafely to work and school. Without the vaccines,
international travel will be dif icult while borders mightremain closed due to the high risk of infection and theconsequent danger to public health. It is in this regard that
universal access to the vaccines must be ensured globally.
Without it, poor and powerless nations will ind it hard to
re-open their economies, thus exacerbating global poverty.
But above all else, everyone has the right to human wellbeing. It is a right that must be protected based on equaldignity of persons.

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Access to Covid-19 vaccines as a fundamental right
Rights are primarily rooted in persons (Nozick 1974). While
the status of rights can be grounded in both procedural andsubstantive aspects, rights are constitutive of the value of
one’s humanity. Such is the nature of human rights. Amartya
Sen (1999) argues that rights are goal oriented. They should

contribute to the real growth of human persons. But at thistime of the Covid-19 pandemic, global institutions andpoliticians have been consequentialist in their approaches.
Vaccines are not supposed to be politicized. But sincecountries and states protect their interests, politics plays arole when it comes to access and prioritization.
An emerging issue is disparity in terms of the percentageof people vaccinated if we look at the demographics. In the
United States, this is a particular issue, considering that
noticeably members of African American communities areway behind compared to others. In rich or middle-classsuburbs, more have been vaccinated compared to places
with predominantly minority residents. The idea is not only
to optimize the goal of achieving targets, but also toequalize the access to vaccines by people. The right to be
vaccinated, hence, concerns a question of justice. The
Rawlsian principle of equal distribution is quite operative inthis case (See Rawls 1971). The Covid-19 pandemic displays
an unprecedented trajectory, hence, the urgent need for a
medical intervention of vaccination is defensible.
Infectious diseases do not respect international borders.
In this way, universal access to vaccines against Covid-19
should not be impeded. Yet, an obvious emphasis on
economic ef iciency glori ies utility, but neglects thefundamental freedoms and primordial rights of people. Sen(2009) maintains that market outcomes and government
actions should be realized in terms of valuable human ends,
including human well-being. But the priority of global
leaders is a return to the business-as-usual attitude which
re lects no real difference to the unjust ways of the past
where global cooperation is secondary to pro it making.
The World Health Organization (2021b) predicts that the
pandemic will put tens of millions of people into extreme
poverty, while the number of undernourished people will
increase to 822 million from 690 million. This means thatpoverty and inequality will persist post-pandemic. Humandevelopment is stunted by Covid-19. With globalization
coming to a sudden halt, human development programs
have been severely affected by the lack of funds. It should be
noted, however, that globalization has stepped on its brakes
due to the inancial crisis of 2008 and trade wars between
US and China.
The Covax Facility of the WHO, which funds the purchaseof the vaccines through the Asian Development Bank andother inancial backers, is an important mechanism. Covax
seeks a fair and equitable distribution of the vaccines at a
discounted rate to ensure that poor countries have an
unimpeded access. The only problem is that there are latentissues that cannot be seen and ultimately, the global
hegemonic order will have an impact on the actual results.
The pronouncement of the EU on strict rules for vaccine
exports is one of those possibilities.
Structural injustice (See Maboloc 2019) or what isdeemed as positional differences in the global socio-politicalorder, in a large way, impede the global effort to put an end
to the pandemic. The challenge henceforth is both internaland external. Internally, there are apparent inequalities insocieties that prevent people from getting their inoculation

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
in a timely way. Externally, global inequalities prevent poor
nations from immediately getting the needed supply of
Covid-19 vaccines from suppliers in developed countries.
Unfair policies initiated by powerful states naturally restrict
the rights of people in developing countries.

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The pandemic in the Philippines
Oxfam (2020) has claimed that in some cases, developing
countries will not get the vaccines until 2022. There was no
mention of the Philippines as a speci ic case, nonetheless.
But some groups see this as a cause for alarm given the factthat the pandemic is affecting the economic well-being ofpeople, with the Philippines economy contracting by 9.5%
in 2020 due to the impact of the pandemic. But while
utilitarian ends are not wrong when it comes to reviving the
economy, the focus right now should be on equalizing theaccess of people to the vaccines. This concerns logisticalrequirements, proper protocols during the vaccinations, theavailability of infrastructures like cold storage facilities, andan effective leadership that can convince the public on thesafety of the vaccines.
The dif icult thing to do right now is to ensure that thevaccines are available to the general population. For
instance, normal classes cannot restart safely because of theperceived risks. The UK variant of the virus, considered as
more contagious, has since been detected by the
Department of Health (2021) in the Philippines. This has
the potential to worsen the situation. Without the vaccines,
life cannot return to normal. The government, however,recognizes the need to balance the economic and physicalwell-being of people.
Beyond the desire to normalize things, there is a need toprotect life to continue the pursuit of equitable progress.
The economy needs to be re-established. However, thePhilippine government is also aware that public safety
cannot be compromised. Although re-opening of somebusinesses would be crucial to revive an ailing economy,
which is projected to grow below 3% this year or half of its
6% growth in the past decade, the leadership of the national
government has opted to prioritize public safety over the
economy. It is a delicate balance since millions of people aregoing through a lot of stress in the absence of a stablesource of income.
Schools too have remained closed, both public andprivate. The students, meanwhile, have exhibited mental
stress under lockdown conditions (Toquero 2020; Eviota
and Maboloc 2021). But the safety of children cannot becompromised. Above all, there is a need to maintain the roleof the government in terms of securing the well-being of thepeople. The availability of the vaccines to everyone is tied toother rights, including the human right to education, theright to livelihood, and the freedom of assembly, rights thathave been set aside in favor of the need to protect publichealth.
The state acts as a father- igure that aims to protect the
public good. The interest of the public is foremost in the
struggle to overcome the pandemic and its effects. Access tovaccines is a human right, and this right can only be realized171

if people have secure access to the objects of these rights.
Vaccines must not be commodi ied. The idea ofprioritization can be morally acceptable if and only if it willserve the interest of every citizen in the state. But the basic
point remains clear. Universal access to the vaccines must
be secured by the government as a matter of fundamental
right.
Conclusion
A right can be viewed as an entitlement. By this we meanthat such cannot be taken from someone since it isconstitutive of one’s humanity. This is what a human right isall about. In this paper, we argued that access to thevaccines must be secured as a human right. The coronavirus
pandemic is a generational challenge. But the science of
medicine is fully equipped with the talent and resources tobe able to combat the disease. What needs to be seen isequal competence of states and global institutions to ensurethat there is a fair and equitable distribution of the vaccines
across the globe. The reason is not just economic, but thefundamental principle of ensuring the protection of humanlife.
References
Castillo-Chavez, C.; Fenimore, PW; Kribs Zaleta, CM; Hyman, A. 2004.
“Model parameters and outbreaks control for SARS.” In Emerging
Infectious Diseases 10: 1258-1263.
Department of Health, 2021. Updates on Novel Coronavirus Disease. https://doh.gov.ph/2019-nCoV
Eviota, G. & Maboloc, CRB, 2021/ Higher Education in the Philippines
during the Covid-19 Pandemic: Psychological Risks, Research
Opportunities, and Implications to Policy. Eubios Journal of Asian andInternational Bioethics, Volume 31, Number 2: 75-79.
Maboloc, CRB. 2019. What is Structural Injustice? In Philosophia:
Philosophical Quarterly of Israel 47 (4): 1185-1196.
Nozick, R. 1974. Anarchy, State and Utopia. New York: Basic Books.
Oxfam. 2020. “Small group of rich nations have bought more than half ofthe future supply of leading Covid-19 vaccine contenders.” Oxfam
International Press Release. [Internet] https://www.oxfam.org/en/
press-releases/small-group-rich-nations-have-bought-more-halffuture-supply-leading-covid-19?
Rawls, J. 1999. A Theory of Justice. Cambridge, Mass: Harvard University
Press.
Sen, A. 1999. Development as Freedom. Oxford: Oxford University Press.
To, KK-W.; Tsang, OT-Y; Yip, Y. 2020. “Consistent detection of 2019
coronavirus saliva.” Clinical Infectious diseases. DOI:10.1093/cid/
ciaa149
Toquero, C. 2020. “Challenges and Opportunities for Higher Education
amidst the Covid-19 Pandemic: The Philippine Context.” In PedagogicalResearch 5 (4): 1-5.
Wang FS. & Zhang C. 2020. “What to do next to control the 2019-nCovepidemic?” In Lancet 396: 391-393.
World Health Organization. “Rolling Updates on Covid-19.” [Internet}
h t t p s : / / w w w. w h o . i n t / e m e r g e n c i e s / d i s e a s e s / n o v e l coronavirus-2019/events-as-they-happen. Accessed January 27, 2021.
World Health Organization (2021b). https://www.who.int/news/item/
13-10-20-2020-impact-of-covid-19-on-people’s-livelihoods-theirhealth-and-our-food-systems. Accessed January 27, 2021.’
Wu JT.; Leung K.; Leung GM. 2020. “Nowcasting and forecasting thepotential domestic and international spread of 2019-nCoV outbreakoriginating in Wuhan, China: a modelling study.” Lancet 395: 689-697.

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Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

A needs analysis of a regulatory
framework for teleconsultation inIndonesia- Antono Suryoputro- Rani Tiyas Budiyanti (Correspondence Author)
Faculty of Public Health, Diponegoro University, Indonesia
Email: ranitiyasbudiyanti@gmail.com- Murni
Healthcare Practitioner, Indonesia

Abstract
This study examines the need for developing a regulatory
framework for teleconsultation in Indonesia. The study was
conducted with 92 respondents in February-March 2020 in theworking area of the Pudakpayung, Rowosari and Pandanaran
Community Health Centers in Semarang City, Indonesia. Half(51%) of the respondents used teleconsultation for healthconsultations, others used it for drug, information, and schedule
checks. The respondents also stated that they fear about themisdiagnosis, privacy, or other issues in teleconsultation (53%).
Further, they expected regulation that protects patient safety,
patient data, and assurance of teleconsultation security. In thiscase, authorized institutions, certain regulations, and developmentof teleconsultation features are needed.

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Background
Teleconsultation is a part of telemedicine. This technology
has developed in Indonesia, including in Semarang city.
These services are in great demand because of various
advantages such as lower costs, lexibility, wider reach, andcan improve health services (Frade et al, 2013). In
teleconsultation service, users can take online medical
consultation, drug consultation, seek health information,
check a schedule, and so on (Frade et al, 2013).
Online medical consultation services can take place
directly (synchronous) using video calls and audio calls orindirectly (asynchronous) using chat, comments on blogs,
web, or social media. Synchronous services enable doctors
and patients face to face communication through themonitor screen, whereas in indirect services patients anddoctors do not have face to face contact (Eric, 1995).
In Semarang City, the Local Government has provided
teleconsultation. It was part of the Integrated Emergency
Management System. The services are known as KONTER
that open 24 hours and are not only used by residents in
Semarang City but also outside of Semarang City (Zainal,2018). There are also many teleconsultation startup
applications in Indonesia. There are many stand-alone
applications, and other applications integrated withhealthcare facilities (Techno Master, 2020). With thisservice, patients can inquire about their health conditions
online without meeting face to face.
Although teleconsultation has a variety of advantages,
there is no speci ic and detailed regulation about it inIndonesia. The Indonesian Ministry of Health has issued
Minister of Health Regulation Number 20 in 2019 regarding
the Implementation of Telemedicine Services between
Health Care Facilities. However, the regulation was not
s p e c i i c a n d d e t a i l e d , a n d i t d i d n o t re g u l a teteleconsultation startup applications that are stand-alone(Ministry of Health Indonesia, 2019).
The phenomenon of doctoroid practice refers to medical
actions performed by someone who is not a doctor but
performs actions that are the authority of the doctor such as
diagnosis, prescription, and so on (Soekiswati & Absori,2019). Many problems can happen when this service isimplemented without speci ic regulation such as thepresence of a doctoroid phenomenon, the uncertainty of thetherapeutic contract, patient safety and con identiality
problems, and so on (Sulistiyono et al, 2019). Therefore we
conducted this needs analysis to develop a teleconsultation
regulation framework to ind what is suitable to be appliedin Indonesia.
Research method
We used quantitative survey and in-depth interviews. The
study was conducted in February until March 2020 in theworking area of the Pudakpayung, Rowosari andPandanaran Public Health Center Semarang City, Indonesia.
There were 92 respondents to the quantitative survey using
closed ended questions of questionnaire, and then 15
informants had an in-depth interview to explore thereasons for their thinking and their expectations related toonline health services. The research location and sample
were selected based on a consecutive technique.
Data collection was carried out by survey and in-depth
interviews to analyze the needs by exploring user
perceptions of teleconsultation (ethical and legal
perspectives). The research was approved by the Ethics
Committee of the Faculty of Public Health, Diponegoro
University.
Results and Discussion
a. Characteristics of respondents
Most of the respondents have education above Senior HighSchool (92%). Most of them also work (51%) with monthly
income above 2.7 million Indonesian Rupiah (IDR) (67%)(Table 1).
Table1: Respondent Characteristics
Variable

Number

%

Woman

58

63.0

Man

34

37.0

Education <Senior High School7

7.6≥ Senior High School

85

92.4

Work

47

51.1

Not work

45

48.9

Income under 2.7 million IDR/month

30

32.6

Income above 2.7 million IDR/month

62

67.4

b. Activity description and reason to do teleconsultation
Based on the data, 51% of respondents use teleconsultation for online medical consultation, 24% forseeking health information, 5% for drug consultation, andEubios Journal of Asian and International Bioethics 31(3) (March 2021)
21% for other reasons such as schedule check. Some
examples comments are:“I use online health services for health consultation. Only
occasionally, my brother tells me about that service. In my
opinion, it’s very helpful and simpler because you don’t need toqueue to see the doctor and the medicine will be delivered
directly to home.”“Yes, to ind health information. Nowadays, modern healthinformation can be accessed online. I usually look for healthinformation from government website or reputable online
health services.”“I often use online health services to check doctor schedules. My
health facility provides an online schedule and admission,
making it easier.”

There were many reasons given to choose the kind of
teleconsultation such as seeking complete healthinformation (34%), good reputation (9%), family
recommendation (27%), feasibility and accessibility (10%),application can help to solve the problem (8%), and others(12%).
Table 2: Considerations about Teleconsultation
Category of comment%

Doctoroid Phenomenon

21.7

Miss diagnosis

3.3

Drug allergy

4.3

Malpractice1.1

False Drug Dose

3.3

No Law Certainty in Teleconsultation

6.5

No monitoring from of icial institution

3.3

Data privacy

4.3

Others5.6

c. Consideration in using teleconsultation
Based on the data, the respondents feel worried when they
use teleconsultation. They were worried about doctoroid
phenomenon (21%) that the person who gives theteleconsultation is not a true doctor. Many respondents also
worried about misdiagnosis (3%), drug allergy (4%),
malpractice (1%), false drug dose (3%), no legal certainty(7%), no monitoring from of icial institution (3%), data
privacy (4%), and others (6%) (Table 2). Some example
comments were:“Sometimes I’m worried, it’s online consultation without video
call. Whether what I’m dealing with really is a doctor or not, I
don’t know..”“I’m worried, whether the diagnosis given is valid or not.
Moreover, it’s done via online or just chatting method.”“If there was an unwanted event, for example wrong
prescription, I don’t know who should be responsible?”

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d. User expectation in online health services
Based on the depth interview, there are many user
expectations that are related with data security and privacy,173

law certainty, and monitoring in teleconsultation. These
were summarized into six major categories:
1. Regulation/law that regulate teleconsultation in more
speci ic details to guide implementing teleconsultation.
2. Monitoring from Department of Health Of ice (DHO) or
authorized institution
3. The feature should be completed with video call(synchronous consultation)
4. Health professional and health services assurance withregistration letter and permit letter
5. Monitoring from Food and Drug Monitor Agency toprevent drug abuse
6. Medical record, data privacy, and data security assurance
Based on data, the selection of teleconsultation is basedon complete features and information in application. Online
medical consultation is an increasingly popular choice inthe community, especially in the COVID-19 pandemic era.
Teleconsultation is considered more ef icient because it
saves time and cost. This is appropriate with a survey
conducted by Deloitte Indonesia in collaboration with Bahar
and the Center for Healthcare Policy and Reform Studies(Chapters) where 84% of users of digital health services
claimed to be satis ied with existing services due topracticality, low cost and many choices that consumers canchoose from (Fika, 2019).
Based on the results, a major reason for teleconsultation
is family recommendation especially for a variety of healthapplications. Online government health services such as
KONTER that have been trusted can be used not only in
speci ic areas but more widely. The accessibility andfeasibility also should be considered in the choice of theteleconsultation application. Patient View White Paper has
revealed the results of a global survey about what patients
expect in health consultation (Patient View White Paper,2014).
In a survey conducted by Deloitte Indonesia incollaboration with Bahar and the Center for Healthcare
Policy and Reform Studies, 16% of users were still
dissatis ied with the existence of digital health services
online (Fika, 2019). It happens because the users were
worried about data security of online health services. This isin accordance with research of Simatupang (2017) thatstates there are 5 most important attributes ofteleconsultation services namely data con identiality,
speci ic information to the illness, easy to understandfeatures, an explanation of the user's health condition andtreatment options available and an integrated medical
record that can be accessed any time (Simatupang, 2017).
The results of a global survey conducted by WHO also
state that in evaluating online health services there is aneed for supervision regarding the dissemination of
information to the public (WHO, 2011).
In addition to data security, there is a major problem inthe development of teleconsultation, cyberattack and cybersecurity that still are challenges in many countries. This was
also found in this study where 22% of respondents felt
afraid if the service provider was not a true doctor so it canlead to misdiagnosis. The problem that arises with the use of

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Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

the application is that a doctor cannot examine the patient
directly, so that it will be dif icult to make a diagnosis of thepatient exactly (Prawiroharjo et al,2019). This condition
also causes the doctor to do little cross-checking of thepatient's condition (Lambert et al, 2012).
Another problem that arises in the use of
teleconsultation services is the possibility of medication
errors or drug overuse or abuse. In this case theadministration of drugs using online consultation healthservices should be monitored.
Even though the consultation is done synchronously, it isvery dif icult to determine with certainty the severity ofpatient's condition. So, the doctor must be careful to givethe treatment recommendation. In this case, the doctor
must consider biomedical ethics principles, the irst is to do
no harm (Lambert, 2012; Young et al, 2010).
Community expectations of teleconsultation services
show the need for regulations to protect the safety ofpatient data, the assurance of doctor and healthcare
facilities that do online health services, and improvementsin the features of applications in online health consultation
services. Especially in online consultation platform
collaboration with healthcare facilities is desirable.
Conclusion
At present, there is a need for teleconsultation integrated
with healthcare facilities. However, speci ic regulations
about protection of customer data con identiality, assuranceof doctor and healthcare facilities, and authorized
institutions that monitor implementation of
teleconsultation in Indonesia are needed. Then theimplementation of teleconsultation will not be contrary to
ethics and laws in Indonesia.
Acknowledgements
We thank the Rector, Diponegoro University for funding thisresearch and the Public Health Faculty of Diponegoro Universitythat supported this research.

References

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Frade S, Rodrigues H. Bene its, 2013. Challenges, and Impact ofTeleconsultation- A Literature Review. Stud Health Technol Inform.
192:1157. https://www.ncbi.nlm.nih.gov/pubmed/ 23920931
Eric B. Allely. 1995. Synchronous and asynchronous telemedicine. Journalof Medical Systems. 19 (3): 207–212
Zainal Ari in. Layanan Konsultasi Dokter (Konter) Dinkes Kota Semarang
Layani 11.911 Pengguna. https://jateng.tribunnews.com/
2018/12/07/layanan-konsultasi-dokter-konter-dinkes-kotasemarang-layani-11941-penggunaTechno Master. Health Application Services are on High Demand due toCoronavirus. Accessed 27 April 2020. https://www.mime.asia/healthapplication-services-are-on-high-demand-due-to-coronavirus/
Ministry of Health in Indonesia. 2019. Ministry of Health Regulation
Number 20 about Telemedicine Services in Healthcare.
Soekiswati, Siti& Absori, Absori. 2019. Law Enforcement to Transcendental
Based of Paramedic Doctoroid Practices in Health Services. Journal ofTranscendental Law;Vol 1(1): 42-57. https://doi.org/10.23917/
jtl.v1i1.8696
Adi Sulistyono, Rani Tiyas Budiyanti, Ayun Sriatmi.A Regulation
Framework for Telemedicine in Indonesia. Eubios Journal. July 2019.
https://www.eubios.info/EJAIB72019.pdf
Fika Nurul Ulya. 2019. Survei 84,4 persen masyarakat puas dengan layanan
kesehatan digital. https://kupang.kompas.com/ read/

2019/08/19/134000926/survei--84-4-persen-masyarakat-puasdengan-layanan-kesehatan-digital
Patient View White Paper, “What do patients and carers need in healthapps”, 2014.
Simatupang A. Atribut-Atribut Sebuah Aplikasi Mobile Healthcare Bagi
Pelanggan Di Indonesia. Program MM Sekolah Bisnis dan Ekonomi
Universitas Prasetiya Mulya. 2017. Avaible from: http://
journal.prasetiyamulya.ac.id/journal/index.php/ibr/article/
download/45/13/.
WHO Publication, Global Observatory for eHealth vol 3, “New horizon ofhealth through mobile technologies”,2011.
Prawiroharjo P, Pratama P, Librianty N. Layanan Telemedis di Indonesia:
Keniscayaan, Risiko, dan Batasan Etika. JEKI. 2019;3(1):1–9. http://dx.doi. org/10.26880/jeki.v3i1.27
Lambert KM, Barry P, Stokes G. 2012. Risk management and legal issues
with the use of social media in the healthcare setting. J Heal Risk
Manag,31(4):41–7. http://dx.doi.org/ 10.1002/jhrm.20103.
Young JD, Borgetti SA, Clapham PJ. 2017. Telehealth: exploring the ethicalissues. DePaul J. Health Care L. 19(3). https://via.library.depaul.edu/
jhcl/vol19/iss3/2 22.
Clark PA, Capuzzi K, Harrison J. 2010. Telemedicine: Medical, legal andethical perspectives. Med Sci Monit, 16(12): RA261-272. PMID
21119593.

Biopower and global justice- Christopher Ryan Maboloc, PhD
Associate Professor, Ateneo de Davao University
Visiting Professor for Global Justice, AUSN
Email: ryanmaboloc75@yahoo.com

Abstract
Michel Foucault describes biopower as the state’s control of thehuman body. In the midst of the crippling coronavirus pandemic,
this implies the subjugation of human beings and the assumptionof an absolute jurisdiction over the civilian population. Foucault’s
method, however, points to the hidden root of the discrimination
against people. The coronavirus era is a manifestation that theworld has not abandoned Eurocentrism nor overcome colonialism.
The interests of powerful states continue to dictate the fate anddestiny of the global poor. The “new normal” is nothing but a reimposition of the unjust ways of the past. Global justice, it can beargued, cannot be recti ied unless we dismantle the prejudiceagainst others. This paper proposes the power of communal values
as an alternative to the state-centric approaches to justice.

Introduction
In a recent report by The Guardian (January 30, 2021), theEuropean Commission has announced tighter rules when it
comes to the export of Covid-19 Vaccines. In the same
report, the paper mentions that European Commission Vice
President Valdis Dombrovskis said: “We paid thesecompanies to increase production and now we expect them todeliver.” (Ibid.) While this announcement does not appear to
be startling, it is nevertheless a morally disturbing
development given the fact that the World HealthOrganization (WHO) wants to see a “fair and equitable” wayof access to the coronavirus vaccines through its Covax
Facility (a pooled purchase of vaccines to ensure universal
access for poor nations).
The powerful European Commission appears to use its
leverage to dictate the terms and policies on vaccine supply
and distribution. But it no longer comes as a surprise. AfterEubios Journal of Asian and International Bioethics 31(3) (March 2021)
all, this has been the way the world is organized from an
economic and political viewpoint. The global hegemonicorder naturally de ines the state of things and powerlessstates have nothing in their hands to prevent the obvious
bias and prejudice against the powerless. Unequal global
structures determine how rules and policies are decided. In
the end, poor societies can only mourn their dead.

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The concept of biopower
According to Daniel Mishori (2020), the concept of
biopower originated in Michel Foucault's The History of
Sexuality. Mishori (2020) writes that biopower addresses“the role of the State in shaping citizens’ health, especially
techniques to control the human body (e.g., reproductive andsexual regulations).” During the coronavirus pandemic, it
can refer to the domination of citizens in the name of apublic health emergency. Public health protocols replace
individual responsibility. The government takes over theautonomy of people when it comes to human well-being due
to perceived or calculated risks and dangers.
Biopower is not a mere concept. It is an “irruption” fromthe usual state of things, which for Foucault is a form of
violence. Indeed, this is the case, insofar as the pandemic
has disrupted globalization, erasing jobs and householdincomes. Covid-19 has infected 104 million across the globe
and killed two million, according to Johns Hopkins
University (2021). But it has not changed the economicorder. As a matter of fact, the pandemic has not in any way
affected large corporations. For example, a report from The
Washington Post in December 2020 has indicated that thebiggest inancial institutions in the United States havereaped billions of dollars in pro it while more than twenty
million Americans were displaced from their jobs.
Foucault’s analysis of power explains the role ofknowledge in history. Power determines the way humansocieties are organized. In Discipline and Punish, Foucault(1975) explains how human beings are reduced into docile
bodies by means of socio-political structures. Authority
creates rules. Human behavior is subjected to it. To control
people, state institutions rein in the people’s basic
freedoms. It is out of the fear of being judged, monitored,
and ultimately punished that the civilian populations would
rather choose to obey. Foucault (1972) writes in The
Archaeology of Knowledge, “We must also describe theauthorities of delimitation: in the nineteenth century,
medicine (as an institution possessing its own rules, as agroup of individuals constituting the medical profession, as abody of knowledge and practice, as an authority recognizedby public opinion, the law, and government.”
Experts, Foucault says: “became the major authority insociety that delimited, designated, named, and establishedmadness as an object.” (Ibid.) When linked to the present
pandemic, we can observe how government health experts
de ine the meaning of public safety, and the risks anddangers associated with the pandemic. The “madness” iseverywhere, as states dictate the application of what itmeans to be a “danger to society.” For Foucault, this issomething that we ind in “the law and penal law in

175

particular (with the de initions of excuse, non-responsibility,and extenuating circumstances.” (Ibid.)
It can be recalled that Albert Camus’ (1947) hero in The
Plague, Dr. Rieux, had rejected the idea that the malady is apunishment from God. That was a necessary pre-condition
for espousing the role of modern science when it comes todiseases. For Foucault (1972), religious authority had set“itself up as the authority that divided the mystical from thepathological, the spiritual from the corporeal, and thesupernatural from the abnormal.” The science of medicine
assumed a privileged place in terms of objectivity. It
possessed the solutions and experts alone know what could
be done.
Colonization and the pandemic
Our analysis, however, must be expanded. Biopower has
developed over time. Its in luence took place during thecolonial period. The story of native people who are
mistreated because of the color of their skin hides
something about the dark past of our modern civilization.
The developments in Europe when it comes to access to the
Covid-19 vaccines only reveal the nature of global politics.
The fate of humankind is determined by nationalist
interests.
Capitalist domination is shown most de initely in humanslavery, a phenomenon that is present to this day according
to the BBC (2016). The exhaustion of physical bodies is asymbol of how the powerful dominates the weak. It can besaid that the dark colonial experience and the lack ofprogress in terms of the level of independence from foreign
in luence of poor countries both exacerbate the situation of
the population at this point. But for Layne Hartsell et al.
(2020), Covid-19 re lects the failure of capitalism and thefree market system.
Stages of colonial experience
Colonization happened in three stages. First, colonial
powers wanted land and territory. To be able to do so, theyused the charm of religion to subjugate the native people. As
soon as foreign conquerors got the trust of the local
chieftains, they had organized a massive religious
conversion of indigenous tribes. The motive was control anddomination. The centralization of authority is a matter ofadministrative ef iciency. But the whole colonial experiencecan only be characterized by two things – extraction andexploitation.
The second stage was the colonization of ideas andbeliefs. With the Enlightenment and largely due to the great
advances made in the natural sciences, reason played acentral role in history. It was in this respect that toeffectively rule the natives, it was necessary to colonize
their consciousness. Language was a tool to polarize local
populations. It helped in the “divide and conquer” policy
against the natives. The native population embraced
modern science as the absolute source of truth, thereby
dismissing indigenous wisdom as myth.
The third stage was economic. With the advances ofmodern man, Eurocentrism meant that the “concept of man”
as an invention of the modern mind is at the center of176

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everything. But who is this man? He is “white” or “fair”
skinned. Thus, began the exploitation of peoples in thename of capitalism and the exploitation of the poor worker.
Oppression reached a global scale, one that is mademanifest in the extreme poverty of 700 million people who
earn less than two dollars a day.
The advance of civilizations represents the stages ofcolonialization. First, there was religion, then the state andits authority, and now, large corporations controlling the
lives of people. The pronouncement of the EU is nothing but
a manifestation of an unjust world that favors the privileged
position of powerful states. The pandemic shows that in the
struggle for biological survival, the white man holds theleverage because he possesses the tools that can exonerate
him from any malady – the state apparatus, science andtechnocracy, and above all, money and politics.
Foucault (1972) says that “we must question those
ready-made syntheses, those groupings that we normally
accept before any examination, and those links whose
validity is recognized from the outset.” Mishori (2020) is
right to say that the pandemic only shows the façade of how
technocratic forces are shaping the world. While poorsocieties and economies are being threatened, powerfulstates continue to assert their hegemonic power. Mishori(2020) explains how “the giants of technocracy…stretched
their muscles…exposing authoritarian regimes, in which
experts, and their particular outlook on reality, science,
medicine and ethics, receive autocratic paternalistic powers
over society.”
Mishori (2020) elaborates that “individual rights were
supposed to be fundamental concepts in most countries, until
recent public policies demonstrated that public healthconsiderations overrun individual rights.” This prognosis
serves to reiterate the concept of the state of emergency.
The inality that we seek, however, when it comes to theclosure of our present predicament, must point toward therealization of a just world for all. All types of critique need adirection to realize the moral ends of society. A potential
solution must lie somewhere.

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Global justice and the pandemic
The problem with the “new normal” is that it is a conceptthat is dictated by the state apparatus. The new normal does
not take into account the idea of difference, nor does it truly
recognize the identities of people out of which their distinct
way of life comes from. The old hegemonic order of theworld will simply continue to make human life dif icult forthe people who live in the margins of society. Before coming
to a conclusion, I will present two views on global justiceand offer an alternative approach in the inal two sections.
The irst comes from Thomas Pogge. Pogge (2007) points tothe “negative duty” of af luent societies not to harm theglobal poor. In this regard, the rich must ensure that trade
policies are not disadvantageous to developing countries.
For instance, the subsidies given to farmers in the US is
unfair to the global poor since it makes the produce in poor
agricultural economies uncompetitive. But during the
pandemic, it is obvious that rich countries are not in aposition to give up their own national interests in favor of
the well-being of the global poor.
The second position comes from Kok-Chor Tan. Tan(2004) argues for open borders. This is to allow themobility of peoples but more importantly, to make available
the opportunities in rich countries to the global poor. The
transfer of talents from countries such as India and thePhilippines, or what is called brain drain, has been provenuseful to the West. Some large tech irms in the US haveforeign nationals as CEOs. In this regard, one can argue for aright to migration in view of the bene its the developed
countries can gain from foreign workers (Maboloc 2020).
But because of the pandemic, at present, outsiders areclearly barred from entry.
The two positions above show that the pandemic will
require complicated solutions if we take into account the
problem of global justice. But in our analysis, it is important
to begin by changing our state of mind. As Camus (1947)
explains in The Plague, the real problem is the attitude ofpeople. Unless we see the suffering of others, it will be hardfor us to realize the value of human life. The problem ofglobal justice is fundamentally moral. Biopower is simply amanifestation of a symptom of a terrible disease – theprejudice against others.
Darryl Macer’s re lection is instructive. Macer (2019)
writes that we do not “need to create some new label so that
all are equal in the eyes of each other, such as man or
woman.” There is something common in people. As a youngman, the bioethicist and geneticist saw something positivein science. Indeed, this is the same message of Dr. Rieux in
The Plague. The idea of decency, Camus (1947) intimates in
his great novel, consists of doing one’s moral obligation tosociety. Every good that a human being is committed to ismeant to save humankind.
“Malasakit” and the power of communal values
In addressing the point of Camus, we must ask : What is ourmoral obligation to society? As an alternative to state
centric approaches such as the above, I would like tohighlight the role of communal values. By this, we mean theability of people to bond together and act for the good of
one’s neighbor. In the context of the Philippines, thisincludes the concept of “malasakit” and “pakikiramay.” Partof our mission in this world is to empathize with thesuffering of others. In the concept of “malasakit,” people
show concern for others. In the instance of “pakikiramay”,
the individual shows compassion and sympathy to aneighbor who is in a dire situation.
In a crisis such as this pandemic, an institution can help
address the concerns of the poor, for example, in terms offood shortages. This is exempli ied by a project done by auniversity in Leyte Province, the Philippines (Agaton 2021).
Such an instance of “malasakit” helps the poor people in a
concrete way. Without the support of institutions in thecommunity, many will suffer while waiting for stateintervention. Commiserating with the situation of others
uplifts the human spirit and empowers human beings intheir communal existence.

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
For the Cebuano speaking Filipinos, there exists theconcept of “tabang” or helping others and the idea of“maayong tao” or being a good person. Someone who sharesto the needy is seen as a good person. In times of crisis, thepoor often ind themselves helpless. But there are people
who act and help those who are in need. This means thatbeing a good person is natural to people in the community,
which includes sharing what one family gives to another,even if one does not have enough. For Hartsell et al. (2020),
Covid-19 is not just a biological phenomenon. As we allre lect on it seriously, there is a social and communal aspect.
In “malasakit,” people understand that the vulnerable
should get the vaccines irst. If a man wears a facemask toprevent the spread of the coronavirus, it shows his“malasakit” for the other and his being a “maayong tawo.” If
one is a good person, then he will consider the interest ofothers before his own, and such can be shown in terms ofprioritizing the vulnerable when it comes to the Covid-19
vaccines. Such is a manifestation of the power of communal
values but also of the ful ilment of our moral obligation toothers, which is rooted in our desire to live well.
Conclusion
This paper is an attempt to analyze the concept of biopower.
Our analysis reveals that it points to a fundamental moral
problem. Our elaboration of the issue of global justicereveals the inadequacy of solutions. The “new normal”, forinstance, is nothing but a re-imposition of the dominantways of powerful states who continue to control and dictate
the lives of the global poor. But we believe in thecommonality of our humanity. It is our moral duty to carefor each other and protect each other, regardless of race,color, or gender. The examination of the concept ofcolonization has allowed us to understand the sophisticatednature of the Covid-19 crisis. The pandemic has become an
opportunity for us to re lect on the necessity of dismantling
not only unjust systems, but the prejudice against others.
But while the above is borne out of the state-centric
approaches to justice, people can bond together and draw
from the community the moral values that can empower
people in a concrete way.
References

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Agaton, S. 2021. “COVID-19 and food security: The Eastern Visayas State
University experience in the Municipality of Burauen.” In Eubios Journalof Asian and International Bioethics 31 (1): 51-54.
BBC. May 31, 2016. “What does modern slavery look like?” https://www.bbc.com/news/world-asia-36416751
Camus, A. 1947. The Plague. Translated by S. Gilbert. London: Hamilton.
Foucault, M. 1972. The Archaeology of Knowledge. NY: Pantheon Books.
Foucault, M. 1975. Discipline and Punish. New York: Vintage.
Hartsell, L.; Krabbe, A.; Pastreich, E. 2020. “Covid-19, Global Justice, and the
New Biopolitics of the Anthropocene.” In Social Ethics Society Journal ofApplied Philosophy (Special Issue): 1-31.
Johns Hopkins University. 2021 Coronavirus Resource Center. https://coronavirus.jhu.edu/
Maboloc, C.R.B. 2020. “The Right to Migration.” In Philosophia: Philosophical
Quarterly of Israel 48 (4): 1501-1513.
Macer, D.R.J. 2019. “Legacies of Love from Christchurch.” In Legacies ofLove, Peace and Hope: How education can overcome hatred and divide.
Macer, D.R.J. (Ed). Christchurch, New Zealand: Eubios Ethics Institute.

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Mishori, D. 2020. “Social Ethics in the Technocratic Corona Era.” In Ethics inContemporary Philippine Society. Ed. Maboloc, CRB. Davao City: SMKC
Publishing.
Pogge, T. 2007. “Severe poverty as a human rights violation.” In T. Pogge(Ed.), Freedom from poverty as a human right. Oxford University Press.
Tan, K.C. 2004. Justice without borders. Cambridge University Press.
The Guardian. January 30, 2021. “EU gives itself power to block vaccine
exports.” https://www.theguardian.com/ world/video/2021/jan/30/
eu-gives-itself-power-to-block-covid-vaccine-exports-video
The Washington Post. December 16, 2020. “The biggest Americancompanies are lourishing during the pandemic and putting thousandsof people out of work.” https://www.washingtonpost.com/graphics/
2020/business/50-biggest-companies-coronavirus-layoffs/

Financial constraints as grave
ethical issues for developing
countries- Farah Wasaya MScN Scholar, MAS, BScN
Aga Khan University School of Nursing and Midwifery
The Aga Khan Hospital, Karachi, Pakistan
Email: farah.wasaya@gmail.com (Corresponding Author)- Sumera Zul iqar, MScN Scholar, BScN
- Anila Ra iq, MScN Scholar, BScN
Aga Khan University School of Nursing and Midwifery

Abstract
This paper aims to illuminate some ethical challenges raised byhealthcare providers through harnessing various ethical principles
and concepts in a clinical scenario, through the theoretical lens ofliberal individualism versus utilitarianism, and the state’s role in
Universal Health Coverage (UHC). The overall responsibility for theprovidence of suf icient health services to each citizen belongs to
the state by taking mitigating measures. A few suggestive
recommendations could be implemented at multiple levels such as
institutional, societal, and national levels to give inancial
challenges a close attention and reduce disparities thus enhancing
positive health outcomes.

Introduction
Health is a fundamental human right of every individual
around the globe. At present more than ever before, people
possess access to essential health services but nearly half of
the world’s population still lacks it (Molkizadeh et al.,2019). Recently, the national statistics revealed a massive
burden on the health taskforce that only 0.82 physicians
and 0.57 nurses are allocated for every 1000 people inPakistan (WHO, 2017). Unfortunately, inancial constraints
become a barrier in approaching health services in lowerincome and middle-income countries (LMICs). Additionally,
according to an estimation drawn by World HealthOrganization (2017), Pakistan spends only 2.8% of its Gross
Domestic Product (GDP) on health. Out of which, thegovernment is accountable for its 36.8% whereas, 55% iscontributed by households through out-of-pocket payments(Kumar & Bano, 2017). The report also revealed thatannually, around 100 million people are driven into extreme
poverty worldwide, due to out-of-pocket expenditure on
health. Even though general taxation is the highest source ofa nation's inances for health expenditure, however, thepublic cannot access health services in Pakistan. Therefore,

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it becomes challenging for the low socioeconomic
population to access health facilities when there is a limited
number of healthcare professionals (HCP) with extremely
expensive services. The literature endorses that poor healthoutcomes are accountable for inancial constraints such aslack of health insurance, non-governmental inancial
support, and high transportation costs to reach healthcare
facilities (Soltani et al., 2019). The key ethical challenge isencountered in the healthcare setting when the treatment
decision lies upon the patient’s incapacity to pay thehospital bills versus his survival chances. Hence, this paper
aims to illuminate the ethical con lict by harnessing various
ethical principles and concepts in a scenario where apatient lost his life due to the lack of inancial support.
Case scenario
The scenario is about Mr. X, a 25-year-old male, presented
with a history of gunshot injury leading to C2 - odontoid
fracture of the spinal cord resulting in him becoming
quadriplegic for a lifetime. After staying three months in thehospital, Mr. X was unable to move but could communicate
through his facial expressions and depended primarily upona mechanical ventilator for survival. Besides, due to having
extreme inancial constraints, the family paid only 15% of
the hospital’s total bill. However, the hospitaladministration and the primary medical team decided towave-off the hospital’s outstanding. Further, they suggested
family either arrange a portable ventilator at home or takethe patient to another hospital for the continuity of caresince multiple patients were waiting in the emergency
department requiring a ventilator. Despite the patient’s
unwillingness, the family had no other choice but to transfer
the patient to another hospital with a heavy heart. During
his way to the other hospital, the patient collapsed due toneurogenic shock and ultimately died because of theabsence of medical help.

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Analysis of the ethical dilemmaThis paper is going to mainly highlight ethical discussions
through the lens of “liberal individualism” versus“utilitarianism” and the state’s role in Universal Health
Coverage (UHC). Out of multiple ethical dilemmas observedin the crux of Mr. X's case, the most inevitable was when
despite the patient’s unwillingness, the family had totransfer the patient to another hospital due tounaffordability concerns. The ethical principle of autonomy
was violated when the patient was provided with a decision
instead of possibilities by the hospital administration. Also,it was very traumatic for the family to get multiple
reminders on an everyday basis to clear the outstanding
bills or else, take the patient to another hospital. After
possessing grounds on bioethical knowledge, the following
propositions could be answered respectively:● Was it ethically justi ied to discharge the on-board,
ventilated patient for the reason they cannot afford
future treatment?
● Who is responsible in this case? Hospitals or the state?
All healthcare professionals take the pledge to care forthe sick sparing no effort to conserve life, alleviate suffering,and promote health with determination. Therefore, it istheir utmost preliminary obligation to prevent the disease
burden by augmenting bene it to the patient. Healthcare
professionals including nurses and doctors often experience
ethical con licts on an everyday basis in a clinical setting
while caring for their patients. These con licts should be
resolved by maintaining moral values and ethical principles
in the practice towards a rational decision that should be in
the best interest of the patient. The ethics in healthcare isentrenched within the health organizational culture and its
environment which expands its ideology with practicalpolicies and procedures to get the greatest rationalized
action. However, the ultimate ethical dilemma arises inhealthcare when there is juggling between the provision ofpatient’s service and preserving inancial sustainability of ahealthcare organization that is either to do good to a single
patient or follow the organizational guidelines andhospital’s business ethics. The hospital has an ethical duty
to give back to society.
Identi ication of the position
In our opinion, life is sacred, and each patient possesses aright to be treated and should be provided an opportunity
to live a quality of life. Based on bioethical knowledge, I
contemplate that patient’s treatment plan and the decision
to withdraw from the ventilator should never be based on
the patient's inancial stability. Moreover, I irmly believethat patient’s outcome could have been far better, and thefamily would not have ended up with such stringent
consequences if the patient either possessed private healthinsurance or held a UHC by the state.
Right based theory versus consequence based theory
The concept of libertarianism refers to the freedom of
choice based on personal autonomy while making decisions(Wissenburg, 2019). It is a right based theory that endorses
the notion of international human rights. Speci ically, in thehealthcare setting, it ensures the essential protection of aperson’s life, liberty, quality care, privacy, information, as
well as freedom from discrimination, torture, and cruel,inhumane, or degrading treatment (Molkizadeh et al., 2019;Childress & Beauchamp, 2001). Concerning the scenario, Mr.
X and his family should have had the treatment continued
with dignity since the concept of libertarianism allows aperson to exercise its right of getting the preferred option oftreatment. An ethical analysis of Mr. X's case illustrates that
all these rights were violated.
However, when it comes to business ethics, theconsequence-based approach is often ruled over the rightbased theory while dealing with patients in healthcare
settings. The concept of utilitarianism proposes that anaction is evaluated as good or bad concerning theconsequence, outcome, or result which brings maximum
advantage (Burkhardt & Nathaniel, 2008). Moreover,Childress & Beauchamp (2001) endorse it to be morebene icence-focused instead of consequence-focused forsociety. Therefore, the decision of hospital administration to
get the patient transfer to another hospital was justi ied inbringing utilization of ventilators to other needy patients in
the hospital.
Autonomy versus distributive justice
At the crux of Mr. X’s case is a question of autonomy and theright to health. In biomedical ethics, the concept of"autonomy" can be referred to as a capacity to live life underself-motives and reasons without being a product of
distorting external forces (Bredenoord, 2016). Likewise, theright to health is the notion that signi ies an equal
opportunity for every individual to receive the highest
attainable standard of health. WHO constitution (1946) andUnited Nation Declaration (1948) have enshrined the “rightto health” as a fundamental right for each human being andmade a legitimate obligation on the state for the provisionof accessible, acceptable, and affordable healthcare of
appropriate quality through human rights-based approach(WHO, 2017).
On the other hand, the concept of justice ensures fair,equitable, and appropriate distribution determined byjusti ied and socially acceptable norms. Whereas
distributive justice in healthcare emphasizes the equitable
distribution of any scarce resources among patients,
notions of distributive justice vary across cultural, societal,
and even individual norms by allowing for discrimination
based on merit or need (Hadler & Rosa, 2018). This
principle is embedded in the concept of equity inhealthcare. Since mechanical ventilators are considered themost scarce and expensive healthcare recourse that often
patients require to keep their survival chances maintained,
the intention of the hospital administration to retrieve theventilator and make it available for the patients waiting in
the emergency room was also justi ied.

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Arguments and counter arguments
The argument persists that every individual in the world
holds the right to life, health, and continuity of treatment incase of health morbidities. According to Leghari (2020), the“right to health” is the health protection and coverage of
unaffordable diagnosis and treatment. Many states haveincorporated this right within their respective constitution
through amendments. Unfortunately, the 1973 Constitutionof Pakistan does not explicitly recognize the right to health.
Article 38 (under the heading of Principles of Policy) only
talks about “necessities of life, such as food, clothing,
housing, and medical relief, for all such citizens irrespectiveof sex, caste, creed, or race” (Leghari, 2020). However, the18th constitutional amendment in 2010 granted exclusive
legislative and executive control to all four provinces overhealthcare. Moreover, the National Health Vision Pakistan
2016-2025 enabled provincial health departments tocontextualize their policy frameworks to achieve UHC. As aresult, many acts and reforms were initiated across thecountry to make substantive progress on sustainable
developmental goal (SDG) 3 and comply with the United
Nations (UN) resolution. A few of these initiatives entail
rural ambulances and mobile health units, increase basic
health units, telemedicine units, immunization, and Sehatff

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

179

Sahulat as a micro-health insurance program (WHOVoluntary National Review – Pakistan, 2019).
Healthcare organizations should not be held
accountable for patients requiring life-long treatments in a
hospital. The decision carried by hospital administration in
the scenario was appropriate considering the hospital’sbusiness. Business ethics provides a set of guidelines to
conduct their operations and transactions in a sociallyacceptable way (Emma & Shaily, 2020). Hospitaladministration is not expected to keep the patients
admitted for the rehabilitation process and hospice care in
the hospital since this may bring male icence instead ofbene icence to Mr. X, in terms of acquiring hospital
infections. Generally, care-dependent patients aretransferred to nursing homes and rehabilitation centersfrom acute care settings. Unfortunately, a very limited
number of care homes and rehabilitation centers are being
operated in the country.
Moreover, the WHO has endorsed the drive towards
UHC and has considered it as one of the most prominent
global health policies. This has made a legitimate
responsibility on the state to provide justice and equality inhealth services across the nation. From the above-discussed
assertions, it is evident that there is an utmost need for UHC
in the country to confront healthcare-related affordability
constraints. According to WHO (2010), UHC provides
inancial protection to the citizens of a country for using
healthcare and ensuring access to required health services(Malik, 2015). However, the WHO Global Monitoring Reporton Tracking Universal Health Coverage (2017) revealed that
Pakistan shows sedentary progress by standing miserable
at 162nd place out of 183 countries on the service coverageindex of the UHC target of the SDG3. Hence, despite theinitiatives taken at the provincial level, more critical efforts
are required by policymakers to reform health policy,
revenue collection, resource pooling, resource allocation,purchasing, and health care provision in the country (Malik,2015). Moreover, private health insurance also plays anactive role in fostering cost-effectiveness and selection of
the desired health organization. However, according toReddy and Mythri (2016), it limits treatment options andaffects the decision making of the primary physician as well.
Justi ication of our position
Based on all the con licting arguments in Mr. X's case, ourstance pertains to be more ethically acceptable for thepatients who are inancially deprived and require continuityof care. The battle of a dilemma confronted by healthcareorganizations between saving Mr. X’s life versus offering
medical facilities to other members of the society willremain a question. But UHC and private insurances can playa pertinent role in this regard and prevent the family fromgoing through a guilt trip and losing life due tounaffordability of healthcare. Moreover, this position is welljusti ied and endorsed by the divine book of Muslims andthe fundamental principles of Islam regarding human rights
such as the right to life, justice, freedom, social security, andprotection against torture (Andrabi, 2010). Furthermore,

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God commands to consider human life as sacred andproclaims saving one life as if saving entire humanity(Qur’an 5:32). This stance is strongly advocated by the
Hippocratic oath as well, which all healthcare professionals
take before commencing professional life. The pledge
contends: “I solemnly promise that I will do the best of myability to serve humanity, caring for the sick, promoting good
health, and alleviating pain and suffering”.
Possible consequence of our position
Our position endorses all the perspectives that come within
the sphere of Mr. X’s right to health treatment despite
experiencing economic restrictions. However, healthcare
businesses do require inancial resources to operate their
hospital facilities and provide quality care to theircustomers. Following our position to continue providing
care to the patient in the hospital without charging a fee
may bring inancial losses to the hospital. Additionally, thismay also result in occupying an expensive and scarce
resource unnecessarily on a patient who can be transferred
to home with transitory arrangements. Also, this will help
avert the accessibility of ventilators to patients in extreme
needs.
Recommendations
The affordability of healthcare services in today’s world is ahuge challenge that requires close attention to enhance
health outcomes and reduce disparities. Implementing ourposition would require recommendations at multiple levels
including institutional, societal, and national levels. At theinstitutional level, all healthcare professionals may provide
training about biomedical ethics to enhance their sensitivity
towards such concerns. Also, increasing the number of
mechanical ventilators in the hospital would help in
confronting the issue related to insuf icient supplies. At thesocietal level, accessibility of care homes and rehabilitation
centers in the community in collaboration with nongovernmental organizations and social support groups
could be bene icial in diminishing the burden to hospitals.
However, at the national level, law, and policy reformation
would play a signi icant role in the investigation, planning,
implementing, monitoring, and evaluating the strategies toprovide health coverage to all citizens. Additionally,strengthening the provincial and state laws against
corruption would ensure access for the deprived
population. Lastly, emphasis to enhance the quality ofprimary healthcare through health promotion andprevention would assist in preventing the disease burden.

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Conclusion
In conclusion, health is a preliminary right of an individual
despite inancial constraints. The medical community often
encounters an ethical dilemma in hospitals while providing
care to patients with intense inancial constraints. Likewise,
Mr. X’s miserable outcome could have been better, if hishealth would either be ensured or if he possessed UHC by
the state. Hospitals have their social and moral
responsibility towards other members of the society who
require health treatments with acute and chronic

conditions. However, the ultimate responsibility ofproviding health services to citizens lies upon the state bytaking mitigating measures. Manifold recommendations
could be implemented at all levels including organizational,
communal, and state levels to help achieve UN resolution
for SDG3.
References
Alzheimer Europe. (2010). Justice. https://www.alzheimer-europe.org/
Ethics/De initions-and-approaches/The-four-common-bioethicalprinciples/JusticeAndrabi, A. A. (2016). Human rights in Islamic perspective. International
Journal of Humanities and Social Science Research, 2(5), 21-26.
Anna, M., Sentot, I. W., & Ismail, R. (2020). Business ethics for hospitalbusiness sustainability. In Proceeding the 2nd International Conference ofBusiness, Accounting, and Economics. (The 2nd ICBAE 2020). http://
digital.library.ump.ac.id/860/
Beauchamp, T., & Childress, J. (2013). Principles of biomedical ethics, (7thed.). New York, NY: Oxford University Press.
Bredenoord, A. L. (2016). The principles of biomedical ethics revisited. In
Islamic perspectives on the principles of biomedical ethics. Muslim
Religious Scholars and Biomedical Scientists in Face-to-Face Dialogue
w i t h We s t e r n B i o e t h i c i s t s . 1 3 3 - 1 5 1 . h t t p s : / / d o i . o r g /10.1142/9781786340481_0006
Burkhardt, M. A., & Nathaniel, A. (2013). Ethics and issues in contemporary
nursing, (4th ed.). Delmar, Austrailia: Nelson Education.
Cookson, R., & Dolan, P. (2000). Principles of justice in health carerationing. Journal of Medical Ethics, 26(5), 323-329.
Emma, N. N., & Shaily, S. A. (2020). How business ethics can enhance thebrand image in the healthcare sector–a case study of Evercare Hospitalin Bangladesh. European Journal of Business and Management Research,5(6).
Hadler, R. A., & Rosa, W. E. (2018). Distributive justice: An ethical priority inglobal palliative care. Journal of Pain and Symptom Management, 55(4),1237–1240. https://doi.org/10.1016/ j.jpainsymman.2017.12.483
Kumar, S., & Bano, S. (2017). Comparison and analysis of health caredelivery systems: Pakistan versus Bangladesh. Journal of Hospital andMedical Management, 3, 1-7.
Leghari (2020). Where is My Right to Health? Courting the Law. https://courtingthelaw.com/2020/03/17/commentary/where-is-my-right-tohealth/
Malik, M. A. (2015). Universal health coverage assessment Pakistan.
https://ecommons.aku.edu/cgi/viewcontent.cgi?
article=1203&context=pakistan_ hs_mc_chs_chs
Molkizadeh, A. H., Kiani, M. A., Baghban, R., Rahmanian, S., & Saeidi, M.
(2019). Right to health with emphasis on children, women, anddisabilities: A literature review. International Journal of Pediatrics, 7(6),9611-9622.
Reddy, M. S., & Mythri, S. V. (2016). Health-care ethics and the free-market
value system. Indian Journal of Psychological Medicine, 38(5), 371.
Siddiqi, S., Iqbal, M., & Aftab, W. (2019). Review of the governance of public
sector hospitals in Pakistan: Lessons for the future. World Hospitals and
Health Services, 55(3), 7.
Soltani, S., Takian, A., SARI, A. A., Majdzadeh, R., & Kamali, M. (2019).
Financial barriers to access to health services for adult people withdisability in Iran: The challenges for universal health coverage. Iranian
Journal of Public Health, 48(3), 508.
Wissenburg (2019). The concept of nature in libertarianism. Ethics, Policy& Environment. 22(3), 287-302, DOI: 10.1080/21550085.2019.1652313
World Health Organization. (2017). Primary health care systems(PRIMASYS): Comprehensive case study from Pakistan. WHO: Geneva.
h t t p s : / / w w w. w h o . i n t / a l l i a n c e - h p s r / p ro j e c t s /alliancehpsr_pakistanabridgedprimasys.pdf?ua=1
World Health Organization. (2017). Tracking Universal Health Coverage:
Global Monitoring Report. https://apps.who.int/ iris/bitstream/handle/
1 0 6 6 5 / 2 5 9 8 1 7 / 9 7 8 9 2 4 1 5 1 3 5 5 5 eng.pdf;jsessionid=DEBB811D70E316BCEFFBCB217AB266D5?
sequence=1

World Health Organization. (2019). Voluntary National Review: Pakistan’s
Implementation of the 2030 Agenda for Sustainable Development.
https://sustainabledevelopment.un.org/ content/documents/
233812019_06_15_VNR_2019_Pakistan_latest_version.pdf
World Health Organization. (2017). Human Rights and Health. https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health

Teaching and learning using online
educational resources forsustainable development incollaborative learning communities- Suma Parahakaran, Ph.D.
American University of Sovereign Nations; Malaysia
Email: sumjayan@gmail.com

Abstract
The sustainable developmental goals (SDGs) were formulated as a
blueprint in 2015 at the United Nations General Assembly, which
has seventeen interlinked goals. The SDGs are intended to beachieved by the year 2030. This review explores the use of OER
and how it could lead to larger possibilities and new frameworks
which can be brought together to explore new insights. The
involvement of learning communities online will help to provide a
broader meaning to trans-disciplinary studies and meaningful
outcomes for the society. The effectiveness of tasks rendered toachieve the SDGs goals require value and ethical oriented actions,which are participatory, inclusive, universal and at the same time
actions which are contextually dependent on local situations.
There are highlights in the reports by SDG scholars on the need tobuild co-dependency of the SDGs through comprehensive
assessments with cross sectoral systems. The integration of online
educational resources for learning communities involves
leveraging knowledge construction, collaborating, sharing
knowledge, social participation and enhanced knowledge, problem
solving skills and attitudes. This review has signi icant
implications in the use of OER for sustainable development. The
discussion includes the scope of the use of OER and the challenges
and strengths for building knowledge for the SDG goals andsustainable development.

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Introduction
The SDGs are intended to be solved through integrated
approaches and actions using cross sectoral knowledge
related to economic, social, and environmental
developmental activities. There are numerous models on
climate change which integrate cleaner air, improved health,and occupation (IGES, 2015). Except for a few SDGs, theinterdependency between the 169 targets of the SDGs needs
to be organized in terms of how they are operationalized(Ilieva, 2017). There is a need for ethical approaches on
governance such as regulatory measures and incentives
among different sectors, where sustainability is concerned(of the SDGs) (Nilsson et al., 2017). The co-construction ofsuch learning content using OER may look challenging but it
could have bene icial effects in the long run.
Online educational resources are teaching and learningmaterials which are free to the public and they are openly
licensed (Washington State University, 2020). There arevarious types of de initions related to what OER stands for.

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To de ine in simple terms, they are online educational
resources which will remain in the public domain and arefreely available under certain terms and conditions.
Online educational resources and collaborative
learning communities
Learning, being a social activity involves learners to engage
in dialogue, communicate, collaborate and intentionally coconstructing knowledge (Jonassen et al., 1999). Slotte andTynjälä de ined collaborative learning as: “creating groups
or learning communities who fundamentally base theirlearning through “mutual learning processes” (2005, p.193).
When OER documents use integrated approaches
between various disciplines, it organizes contents into
context in education, in multicultural contexts and helps toprovide meaningful learning to learners or users in the OER.
Learners can contextualize the knowledge closest to theirsocial reality. Insights from the teaching and learning
processes from collaborative learning communities result inbuilding content and possibility of new insights dependingon the quality of the teaching contents and the tools used.
The challenges facilitators will have to manage whileworking with OERs are many such as: managing structured
collaborative work, facilitator expertise, validation ofindings to be discussed by subject experts, organized
inputs, interpretation of cultural and contextual issues, andorganizing the contents built in teamwork.
Considerations while using OER
Effective learning models for online learning have shown
three attributes: active learning, cooperative learning,learning through problem solving approaches (Pinchevskyet al., 2015). Collaborative learning communities working
on the OER enable learners to have personal interactions
which re lect the social reality and require mutual respect
while interacting online and of line. Other areas which
online learning communities develop are: development ofshared goals, trust and mutual support (Shea et al., 2006).
“At their best, online learning-community models allow
participants to actively engage one another in ideas andperspectives they hold to be educationally worthwhile,
exciting, and provocative. It is through the design of thelearning environment, with an emphasis on sharededucational goals, support, collaboration, and trust that theseprocesses can be most effectively and functionally activated”(Shea et al., 2006, p.177).
The online learning collaborative framework by Garrisonand Arbaugh included important components such as:
developing and maintaining teaching presence, fostering asocial presence, and exploring cognitive processes. The
mediating factors that set the climate for teaching andlearning are: factors supporting discourse, setting climate,selecting content (Garrison & Arbaugh, 2007; Garrison et al.,2000). Teaching presence requires learners to “seekinformation, brainstorm ideas, provide personal narratives
and question themselves and others while exploring the
problem. In achieving critical thinking, it is important tounderstand that it is both a process and a product. As aprocess, consideration needs to be given to metacognition”

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)(Garrison et al., 2001p. 272). Teaching must include in
depth learning and “meaningful understandings as well as
content speci ic critical inquiry abilities, skills anddispositions” (p.8). For enhancing learner support,
facilitators must facilitate learning with trust, supportive
engagement, and the ability to share the educational
experiences together with learners (Shea et al., 2006).
Linkages, nested-ness, networks in OER
The contents for OER can also integrate interdependent
linkages of factors that impact each other, related to thecontents on environment, health, and education (fromvarious disciplines) to produce a network of knowledge.
The contents produced through such linking will enableknowledge accumulation within communities and to othercommunities in various states and within cities, ruralvillages and local to global domains. The use of OER is
predicted to support knowledge integration into systemic
thinking concepts from health and the environment. It will
enable the concept of forming networks of hierarchicalknowledge. The overall impact will include linkages andnetworks between and within learning communities. This
calls for all students to manage their learning through basic
internet facilities both as a requirement and from a humanrights perspective.
The above networks of knowledge can be enabledthrough different domains of sciences because there exist
common structural and dynamic patterns in large systems
from domains of sciences, nature and technological ields
and a common set of tools will enable their analysis(Barabási & Pósfai, 2016). For example, Manuel et al.,(2019) quoted a study from Dalsgaard et al. (2013) and
explained the idea of how climate change can impact thenested-ness and modularity of pollination networks. The
in luences were different from mainland when compared toislands and the indings revealed that on the mainland there
were positive signi icant change in quaternary changes due
to climate change whereas in the islands, there were noobserved changes. The information and the data can be
integrated in OERs along with comparisons of such similar
patterns in other communities.
Network science will have “the main theoreticalmechanisms conceived to explain the emergence of nestedness in ecological and socio-economic networks; theimplications of a nested topology of interactions for thestability and feasibility of a given interacting system”(Manuel et al., 2019, p.1).

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Cause and effects of human actions in the OER content
The integration of the contents related to the SDGs into the
OER document will enable learners to view the interactive
dynamics between various factors. Different perspectives
will enable critical thinking in learners, and they will becompetent to argue logically why certain precautionary
principles must be taken for speci ic actions and decision
making. There are a lot of contents in sciences where ethics
is either taught as a separate discipline and the logicaldiscussions are left out of the scienti ic facts and arguments
and vice versa. The contents of online educational resources

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permit lexibility in addition to contents and can also
integrate various disciplines in the future. Learners will
move from simple to complex mode of learning and thelearning processes can be co-constructed throughcollaboration. This will be engaging, motivating, andinteresting as long as learners are able to organize learning.
The only challenge is that the learning outcomes cannot be
assessed for all learning objectives as there may be
emerging insights due to such collaborative and processbased learning. This may have an impact on how
assessments are done in the future.
The integration of contents related to environmental
impacts such as damage to coastal reefs, ecosystems,
freshwater depletion and contamination, wetland loss anddamage, climate change, forest clearance and land coverchanges, technological integration such as nanotechnology
will enable cross sectoral contents which will enhancelearners’ understanding and learning of systemic thinking.
Cross sectoral contents can be integrated in OER to
address learning for the SDGs. Education requires anintegration of the knowledge and insights for sustainability
in environment and health of societies. Teaching of science
requires teaching of ethics (Reiss, 2011). Environmental
ethics can be taught using many different dimensions. It canbe stated that: “Environmental ethics teaching can also occur
in the context of moral education, as part of “values
education” or philosophy education. Environmental concerns
have social, political, economic, technological, spiritual, andaesthetic dimensions, so environmental ethics can be taught
from a variety of academic contexts. Environmental ethics
can be taught as a cross-curricular discipline or taught acrossand within many subjects” (Baker et. al., 2019, pg.11).
When there are many different linkages of cross sectoral
information in the document it will have to be structured
and assessed, validated by experts for their indings or the
emerging insights and re-modi ied, reconstructed, andre ined to form a whole coherent system of knowledge.
These intricate processes if implemented well, will bebene icial to policy making.
Collective transformation in health & the environment
Case studies and best practices can be used in online
educational resources with transformative lessons which
impact both social, economic, and environmental conditions
within a locality. Local knowledge should be given equal
importance as much as globally oriented environmental
knowledge. OER can integrate contents so that there is acontinuity of knowledge content. Best practices andknowledge gaps can be addressed when there are multiple
learners attempting to co construct knowledge from various
ields.
An example is the sustainability practices related to caseof the Lisheen mine closure. The mine located in North
Tipperary, Ireland was operating since 1999 and was
expected to close by 2005. As responsible stewards the aimof the participants was to leave a positive legacy which
included providing a better social impact and pro
environmental actions. Multiple stakeholders came together

to not only create closure but also rehabilitate the land
which is 45% rock capped. They transformed 8.5 hectares
to agricultural pastureland (Vedanta resources, 2018). Thisis an example of collective transformative act which
involved restoration of social conditions, pro environmental
behaviors, reversal of health consequences of the ecosystemand the health and economy of people. Furthermore, there
are valuable bene its in using OER for accumulatingknowledge and critical thinking as they will lead learners to
improve their critical thinking skills and problem-solving
capabilities. Learners will gain cooperation, problem solving
and decision-making skills using OERs.

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OER contents for sustainable development practices
There are many countries who are deprived of proper living
conditions and do not have the same privileges even within
their own locality. They include factors related to lower
socio-economic conditions, rapid urbanization, migration ofpeople, rock capped mining land which has not been
restored, and lack of natural resources and less exposure toscienti ic information for solving daily issues in societies.
The WCED (1987) recommended that to reverse
unsustainable trends, quality of life depends on: “reviving
growth, transforming the quality of growth, meeting essential
needs and aspirations for jobs, food, energy, water andsanitation: regulate population, conserve and enhance theresource base, reorient technology and manage the risk, andinclude and combine environment considerations in decision
making” (Sustainability development in practice, p.5).
The use of OER in aquaculture and isheries in higher
education courses have bene its and barriers. A study by
Pounds & Bostock (2019) explored the bene its and barriers
of using OER materials. Educators stated that OER can be ofhigh quality, it can save time while preparing lessons, leadto higher quality teaching, remove socioeconomic barriers,
easy to modify and use. In the same study it was reported by
students that there will be access to knowledge andknowledge is a basic human right, bene its are morecompared to investing in educational materials and that
their teachers would have more time to spend with them ifthey used online education (Pounds & Bostock, 2019, pg.
700-701). According to educators and students, the lack ofawareness, lack of trust in quality, dif iculty in modifying
resources, and type of language used were major barriers tousing OER (Pounds & Bostock, 2019). There are also issues
in searching for OERs according to researchers(Abeywardena, Gajaraj & Chan, 2012). Other barriers
include sustainability in adopting OERs when initial funding
allocations for OER was depleted (Luo, Hostetler, Freeman,& Stefaniak, 2019).
The challenges that learners will confront will be inshifting from traditional modes to online mode. They will be
required to manage their own independent learning andre lective practices both as an individual and using
collaborative methods of learning. Apart from technicalcompetencies students and teachers must be competent inusing online education and integrated approaches to
explore the cause and effects.

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The content can be integrated with encouraging andpositive highlights to promote the following: ‘promoteharmony and spirit of common brotherhood, transcending
religious, linguistic and regional or sectoral diversities;
renounce practices derogatory to the dignity of women; value
and preserve the rich heritage of our composite culture;protect and improve the natural environment; develop thescienti ic temper; abjure violence and strive towards
excellence in all spheres of individual and collective activity sothat the nation constantly rises to higher levels of endeavor
and achievement (DEPFE, NCERT, pg.41).
Teachers’ use of the content will also impact the ways
students learn. The recommendations and insights from theindings or learning outcomes from such large documents
will cut across trans-disciplinary domains.
Conclusion
The human capital of a country depends on the economy
which in turn depends on the cultural, social, political, andenvironmental quality and development. Ex-Prime Minister
Abdul Khalam from India stated that like China and the USA,
India has to invest in research so that there will be
expansion of industries to lead the economy of the country(Parahakaran, 2018). The advantages of online educational
resources can be extended to workplaces in the form of tacitknowledge or practical knowledge. The global need is to
educate everyone and OER deployment is one of the mostsigni icant contributors to ful il equity gap, sustainability ofhealth, environment, and education. This review on the useof OER generally for the SDGs and other cross sectoral areas
reveals the possibility of new insights for transdisciplinary
studies and new teaching and learning arrangements. The
discussion of the challenges and strengths also assert thatthe use of OER is going to make signi icant changes in policy
making, governance, teaching and learning outcomes andfor achieving the SDG goals by 2030.
References
Abeywardena, Ishan & Gajaraj, Dhanarajan & Chan, Chee Seng. (2012,
September). Searching and locating OER: Barriers to the wider adoptionof OER for Teaching in Asia. Proceedings of the Regional Symposium on
Open Educational Resources: An Asian Perspective on Policies andPractice, Penang, Malaysia.
Baker, M., Grundy, M., Junmookda, K., Macer, D.R.J., Manzanero, L.I., Reyes,D., Ngo, T,T., Waller. A. (2019). Environmental ethics education.
Christchurch: Eubios Ethics Institute.
Barabási A.-L., Pósfai M. (2016). Network science. Cambridge University
Press.
DEPFE, NCERT, (n.d). Education in Values: A Framework, Department of
Educational Psychology and Foundations of Education National Councilof Educational Research and Training. Sri Aurobindo Marg, New Delhi,
India.
Dalsgaard B., Trøjelsgaard K., Martín González A.M., Nogués-Bravo D.,
Ollerton J., Petanidou T., Sandel B., Schleuning M., Wang Z., Rahbek C., etal. (2013). Historical climate-change in luences modularity andnestedness of pollination networks, Ecography, 36 (12) (2013), pp.
1331-1340.
Garrison, R.D., Anderson, T., Archer, W., (2000), Critical inquiry in a test
based environment: Computer conferencing in higher education. Interand High Edu, 2, 87-105.
Garrison, D. & Arbaugh, J.B. (2007). Researching the community of inquiry
framework: Review, issues, and future directions. Internet and Higher

184

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

f

f

f

f

f

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Education - INTERNET HIGH EDUC. https://doi.org/10. 157-172.
10.1016/j.iheduc.2007.04.001.
Garrison, D. R., Anderson, T., & Archer, W. (2001). Critical thinking,cognitive presence, and computer conferencing in distance education.
American Journal of Distance Education, 15(1), 7−23.
Griggs, D., Stafford-Smith, M., Gaffney, O., Rockström, J., Öhman, M. C.,
Shyamsundar, P., Steffen, W., Glaser, G., Kanie, N., & Noble, I. (2013).
Policy: Sustainable development goals for people and planet. Nature,495(7441):305–307. https://doi.org/10.1038/ 495305a
IGES. (2015). Achieving The SDGs: From Agenda To Action. Hayama, Japan:
IGES. http://www.iges.or.jp/en/sdgs/
Ilieva, R. (2017). Urban Food Systems Strategies: A Promising Tool for
Implementing the SDGs in Practice. Sustainability, 9, 1707. https://doi.org/10.3390/su9101707
Jonassen, D.H., Peck, K.L., & Wilson, B.G. (1999). Learning with technology:
A constructivist perspective. Upper Saddle River: Prentice Hall, Inc
Luo, T., Hostetler, K., Freeman, C., & Stefaniak, J. (2019). The power of open:
bene its, barriers, and strategies for integration of open educational
resources. Open Learning: The Journal of Open, Distance and e-Learning,
1-19. https://doi.org/10.1080/ 02680513.2019.1677222
Manuel, S,M., Zhuo-Ming, R., Jordi, B., Claudio, J, T., (2019). Nestedness incomplex networks: Observation, emergence, and implications, Physical
Reports. 813. 1-90. https://doi.org/ 10.1016/j.physrep.2019.04.001.
Olsen, S.H., & Zusman., E. (2016). Taking Action on the Sustainable
Development Goals, https://www.iges.or.jp/en/ publication_documents/
pub/discussionpaper/en/5627/Taking+Action+on+the+SDGs.pdf
Parahakaran, S. (2018). Learner support services for distance learning forsustainable collaborative learning communities: Issues in the Developing
Countries. In Technology for Ef icient Learner Support Services in Distance
Education Experiences from Developing Countries. Springer publications.
Doi: 10.1007/978-981-13-2300-3
Pinchevsky-Font T, Dunbar S. (2015). Best Practices for Online Teachingand Learning in Health Care Related Programs. The Internet Journal ofAllied Health Sciences and Practice. Jan 01; 13(1), Article 8.
Pounds, A., & Bostock, J. (2019). Open educational resources (OER) in
higher education courses in aquaculture and isheries: opportunities,
barriers, and future perspectives. Aquaculture International. 27,
695-710, 27. 10.1007/s10499-019-00355-9.
Shea, Peter & Li, Chun & Pickett, Alexandra. (2006). A study of teachingpresence and student sense of learning community in fully online andweb-enhanced college course. The Internet and Higher Education. 9.
175-190. 10.1016/j.iheduc.2006.06.005.
Slotte, V., & Tynjälä, P. (2005). Communication and collaborative learning atwork: Views expressed on a cross-cultural e-learning course.
International Journal on ELearning, 4(2), 191−207.
Sustainable Development in Practice (2004). Case studies for engineers
and scientists. A. Azapagic, S. Perdan and R. Clift (eds.). John Wiley &Sons, Ltd.
Vedantaresources (2018). https://www.vedantaresources.com/ Pages/
WhoWeAre.aspx
Washington State University (2020). Open Educational Resources (OER):
Tools for affordable learning, https://libguides.libraries.wsu.edu/
affordablelearning/de iningoers

Challenges for organ recipients andelderly people in summer of 2020
during the COVID-19 pandemic- Maria-Keiko Yasuoka, Ph.D.
Visiting researcher in Medical Anthropology and Medical Ethics,
Graduate School of Health Sciences, Hokkaido University, Japan;
AUSN Visiting Professor of Medical Anthropology and Medical
EthicsEmail: mkya11@let.hokudai.ac.jp

Abstract
Due to climate change, we had a long hot and-humid summer
throughout Japan from June to September 2020. In addition,
during the COVID-19 pandemic, the requirement to wear masks
regularly meant that organ recipients and elderly people struggledwith heatstroke. On June 25, 2020, the U.S. Centers for Disease
Control and Prevention updated and expanded the list of increased
risks for becoming severely ill from COVID-19. Elderly people
remain at increased risk, but age- and condition-related risks were
further de ined. I focus on (1) immunocompromised state
following a solid organ transplant, (2) chronic kidney disease, and(3) residents of care homes for elderly people.
Because organ recipients are immunocompromised, thenumber of COVID-19 victims among them has increased. The Japan
Society for Transplantation created a COVID-19 committee toinvestigate and discover medical treatments and infection control
and management practices. It also shared the updated datainternationally to minimize the spread of the novel coronavirus.
Chronic kidney disease patients are organ recipient candidates
who are also dialysis patients. On March 9, 2020, the Japan Society
for Transplantation called for organ transplant operations to bedelayed (not prohibited but mostly stopped). As a result, the mostserious risk for recipient candidates is a longer wait for an organ,with no clear plan to restart transplantations during the pandemic.
Other people at high risk are elderly care home residents. Most
care homes implemented a ban on visitors during the pandemic
but still experienced clusters of COVID-19 cases. Various risks for
elderly care home residents have become evident over the last six
months. One of these, as noted by the Japan Geriatrics Society, wasthe worsening risk of dementia, which increased by 40% in thispopulation.

COVID-19 in Japan (Spring 2020)
In Spring 2020 (Yasuoka, 2020), we expected that abeautiful summer would come, and we could enjoy life after
a quick end to the novel coronavirus global pandemic. We
were still dreaming about overseas travels that year as
usual. The long history of COVID-19 during this past year
started with the irst patient reported in Japan on January
16: a Chinese man who lew back to Japan from Wuhan. On
February 13, another victim of COVID-19 was reported: awoman in her eighties whose son-in-law was a taxi driver;
he also succumbed to coronavirus and passed it on to hismother at home. On February 27, schools closed
temporarily across Japan. On March 9, an expert meeting
was called to avoid Sanmitsu (the 3 Cs: closed spaces,
crowded places, and close-contact settings) in public andour daily life and inally the World Health Organization(WHO) characterized COVID-19 as a pandemic on March 12(WHO, 2020). In addition, on March 24, the President of theInternational Olympic Committee, Thomas Bach, and thePrime Minister of Japan, Shinzo Abe, held a conference calland mutually agreed to postpone the Tokyo Olympic Games
to 2021 (IOC, 2020).
A stay-at-home policy was requested during March 25 toApril 12 in Tokyo. On April 7, the National Diet of Japan (theJapanese government) gave the Prime Minister power todeclare a partial state of emergency in seven prefectures(Tokyo, Kanagawa, Saitama, Chiba, Osaka, Hyogo, andFukuoka) under the Novel Coronavirus Special Measures
Law until May 6. However just four days after the end of thestay-at-home policy, on April 16, the declaration of a state of
emergency was expanded to include the entire country ofJapan. Furthermore, six more prefectures (Hokkaido,
Ibaraki, Ishikawa, Gifu, Aichi, and Kyoto), along with theoriginal seven, were designated “special security
prefectures” where efforts were needed to focus on
preventing the spread of the novel coronavirus until May 6.
The number of COVID-19 infections reached over 10,000
patients on April 18, just days after a nationwide state of
emergency was declared in the irst wave in Japan (Scott,2020).

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COVID-19 in Japan (Spring to Summer 2020)
When I gave a presentation at the Tenth International Public
Health Ambassador Conference (IPHA10) on 3 October
2020, autumn had come to my hometown, Sapporo. Who
could have imagined that we would hold the tenthconference virtually instead of in-person, like so many
international conferences, and that so many more would becancelled throughout 2020?
Japan had a long hot and humid summer from June –September due to climate change. In addition, the COVID-19
pandemic was very active during the summer, and therequirement to wear masks meant that people struggledwith heatstroke. The state of emergency declared on April 7
was inally lifted across Japan on May 25, marking the endof a six-week lockdown during which only visits to hospitals
and grocery stores were permitted. On June 2, because thenumber of newly infected people showed evidence of adeteriorating situation, a “Tokyo alert” (call for caution) was
triggered and the rainbow bridge was lit up red until June
11 (NHK, 2020).
On June 19, restrictions on inter-prefectural travel werelifted and people could go anywhere within Japan.
Restaurants reopened and some events such as baseballgames could be attended, while following guidelines. The“Go to Travel” campaign began on July 22, and thegovernment provided coupons for discounted travel feesand souvenirs, except in the Tokyo area, in the hope ofstimulating the economy with more public spending on
tourism. However, it was dif icult to restart socioeconomic
activities in stages while also satisfying infection prevention
requirements, and novel coronavirus infections climbed to
new heights of roughly 795 per day. By July 29, a record
high of over 1000 infections per day was reached, and theirst infections in the 47th prefecture, Iwate, were reported.

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On August 20, the infection control sectional committee
recognized that the second wave of COVID-19 had hit apeak, and that scrupulous attention was required to besensitive to changes in infection status in the future. On
August 28, the government promised to provide
vaccinations for everybody in Japan by mid-2021, but both
specialists and the public thought it unlikely that theywould be (safely) available by that date. On September 5,
WHO warned against rushing to create a vaccine because itis necessary to ensure their safety and ef icacy during a long
trial period. WHO also noted that vaccines should beallocated fairly and distributed internationally among richand poor countries.
However, the novel coronavirus did not wait for scienti ic
developments in vaccines, and Tokyo recorded 218 newcases of the coronavirus on September 19, the second day ina row that the number rose to over 200 in the capital.
Autumn came and the government was worried about
simultaneous infections with both in luenza A or B virus
and COVID-19 in the winter. The health ministry advisedthat people aged 65 years or older should be given lu shots
irst from October 1, and that people under 64 would
receive them from October 26. However, many elderly
people could not get the vaccines so quickly (e.g., I got the
shot on October 26, but my mother’s elderly care home wasdue to receive it in November). Elderly people’s families
became increasingly worried about clusters of infections incare homes (Matusmoto, 2011).
Masks and heatstroke
Japanese people often wear masks when we catch a cold inwinter or during hay fever season in spring. Many
foreigners wonder why Japanese people wear masks
regularly when they are out downtown. In fact, this has
been a custom since the Spanish lu of 1918, and maskwearing is known to be effective at protecting against
viruses. But we wear masks only in winter and spring but
not summer: we wear them not only to protect against
viruses but also to keep in moisture and feel the warmth. I
wear masks more often than the average Japanese person
because I live in northern Japan, and I choose to protect mynose and mouth from the coldness and dryness of thisregion in winter. Usually, we use them to protect ourselvesfrom pollen in spring and we stop wearing masks after
spring; nobody wears masks in summer because it is too
hot.
In 2020, due to climate change, we had a record long, hot
and humid summer throughout Japan. Mask-wearing was
mandatory to prevent infection: to avoid catching the novel
coronavirus or giving it to others. This was the irst timethat even Japanese people had worn masks in summer, andit became clear that it was too hot to wear them. The
temperature inside masks reached more than 40 °C and,
which is worse, too much moisture accumulated insidethem, meaning that people could not feel thirst: this caused
dehydrating illnesses which led to death in some cases.
Since wearing masks in summer can lead to heatstroke, we
had to decide between avoiding novel coronavirus or

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heatstroke, controlling our mask-wearing to avoid bothadverse effects (Yokobori, 2020).

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Updated lists of those at increased risk
In spring 2020, the people at highest risk of COVID-19
infection were elderly people aged 65 years and over andpatients with pre-existing conditions such as cardiac
diseases and chronic respiratory illnesses. On June 25, theUS Centers for Disease Control and Prevention (CDC)
updated de initions of the people at increased risk withmuch more speci ic detail and added other people who
were advised to take extra precautions, based on the latest
data (CDC, 2020).
The updated CDC de initions focused on individual age
and medical conditions of those at high risk, but also
highlighted quality of life in more detail than before. They
pointed out that the risk of severe illness from COVID-19
increases with age; this means that for patients who haveserious underlying illnesses, their age is an important factor.
Older adults with severe illnesses are at the highest risk, sothey need extra individual care. Further, the risk of severe
illness increases with not only with age but also with otherfactors, and more individual environmental factors havebecome intertwined. While aging is a risk factor for
everyone, communities contain aged people in a variety ofsituations. For example, the risk levels are different for anelderly person who lives at home alone, or with family, or ina care home with many other people. Thus, we cannot
categorize people only into risk groups of older or younger
than 65 years.
The CDC also expanded the category of people of any age
with certain underlying medical conditions who are atincreased risk of severe illness from COVID-19, and again
highlighted quality of life issues. The updated de initions
show that a variety of people are at high risk of contracting
the novel coronavirus, and individual conditions areimportant factors. It is therefore dif icult to de ine one
category of “those at highest risk,” and the CDC cautionedthat more careful countermeasure development is needed,in line with the latest evidential data, as soon as possible. It
is possible that the de inition of “high risk” itself is unclear
and changeable during this pandemic, because the virus
itself is so unpredictable (Coates, 2020).
The revised de initions expanded on the kinds ofunderlying disease categories and speci ic examples andalerted the world to increases in risk severity in patients
with: cancer, chronic kidney disease, chronic obstructive
pulmonary disease (COPD), heart conditions, such as heart
failure, coronary artery disease, or cardiomyopathies,
immunocompromised state (weakened immune system)from solid organ transplant, obesity (body mass index [BMI]of 30 kg/m2 or higher but <40 kg/m2), severe obesity (BMI
≥40 kg/m2), pregnancy, sickle cell disease, smoking andtype 2 diabetes mellitus.
My research particularly focuses on people of any age
with the following conditions, acknowledged by the CDC as
being at increased risk of severe illness: chronic kidneydisease and immunocompromised state (weakened immune
system) from solid organ transplant.
Most chronic kidney disease patients depend on blood
dialysis. In Japan, they also face further risk because thedialysis facilities are close together, so they are more likely
to encounter other people and be at risk of contracting
COVID-19. Also, after a solid organ transplant, organ
recipients need immunosuppressant drugs to avoid organ
rejection, meaning that their bodies’ immune systems areseriously weakened (Yasuoka, 2019).
Higher risk of severe illness?
The CDC presented visual information about what to do if
you are at higher risk of severe illness from COVID-19 or if
you know someone at higher risk. This includes several
categories, as set out below.
Older adults
The CDC informed older adults about how to reduce the riskof catching the novel coronavirus: this is especially
important for people at increased risk of severe illness fromCOVID-19 and those who live with them. The best way toprotect yourself and to help reduce the spread of the virusthat causes COVID-19 is to: limit your interactions withother people as much as possible; take precautions toprevent getting COVID-19 when you do interact with others;
get in touch with your healthcare provider within 24 hours
if you start feeling sick and think you may have COVID-19.
People with underlying medical conditions
Adults of any age with certain underlying medical
conditions are at increased risk of severe illness fromCOVID-19, de ined as hospitalization, admission to theintensive care unit, intubation or mechanical ventilation, or
death, as noted in the updated CDC de initions above.
COVID-19 is a new disease. Data are currently limited andinformation about the impact of many underlying medical
conditions and whether they increase the risk of severe
illness from the novel coronavirus is lacking (Kaser, 2020).
Immunocompromised patients
Immunocompromised patients include recipients of all
kinds of solid organs and organ (mostly kidney andpancreas) recipient candidates who are users of blood
dialysis.
Organ transplantation is a kind of miracle medical carethat saves patients’ lives by transplanting others’ organs
into their severely ill bodies. However, our bodies naturally
reject others’ organs, so organ recipients must avoid this bydecreasing their immunity (Caplan and Coelho, 1999). They
must take immunosuppressing drugs to avoid organ
rejection. As a result, their bodies become
immunocompromised and their risk of contracting
COVID-19 increases (Loupy et al., 2020). Organtransplantation is a wonderful medical treatment, but it
produces bodies weakened in their ability to ight all kindsof infection. An infectious pandemic can prove especiallyfatal for solid organ recipients (Lock, 2002).
Due to severe organ shortages, many recipient
candidates have been waiting for an organ donation while
undergoing dialysis. The number of patients on dialysis with

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

187

type 2 diabetes is increasing year on year, compared tothose who are on dialysis due to kidney failure, who tend tobe younger. As a result, the average age of patients
undergoing dialysis is increasing, leading to a higher
number of elderly dialysis patients. The risk of infection in
dialysis patients is higher; in addition, many type 2 diabetes
patients must receive blood dialysis together, which puts
them at high risk and causes further stress.
While the original diseases and symptoms differ, organ
failure and diabetes patients must spend large amounts oftime together during dialysis, and this also leads them toexperience similar complications and side-effects such as
hypertension or high blood pressure. As a result, they may
be at increased risk of severe illness from COVID-19.
Kidney/pancreas organ recipient candidates have suffered a
disease suf iciently serious to need organ transplantation,
but they face organ shortages and must wait for organ
donation. Since it is not possible to know when this mightoccur, they may be on blood dialysis for long time (one or
two decades) (Himmelfarb and Ikizler, 2018). Most organ
recipient candidates suffer various kinds of complications,and this reduces their immunity against infections (Cooper
and Cooper, 2014). In addition, they must commute to blood
dialysis facilities three days per week and have to stay for
four hours in one large room, sharing it with other dialysis
patients. As a result, many clusters of infection have been
breaking out (Yasuoka, 2020).

which is a mushroom (a Kampo medicine). COVID-19 is a
novel coronavirus for humans, but doctors and healthresearchers have been investigating new medicines or
supplemental drugs based on traditional medicine for sometime. This is a great opportunity to make use of traditional
knowledge based on ancient wisdom, because humanhistory is a history of battles with viruses, and people havesurvived using traditional knowledge and experience fromlongstanding medical heritage (Chen et al., 2020).

COVID-19 Committee
The Japan Society for Transplantation (JST) created the
COVID-19 Committee, chaired by Dr. Kenji Yuzawa, who isliver and kidney transplant surgeon, for organ recipientsand recipient candidates on February 26, 2020 (JST, 2020).
This committee’s members include not only organtransplant surgeons but also various specialists such as
infectious disease experts, who are all Japanese but workthroughout Japan and across the US. The aims of thiscommittee are to investigate and discover medical
treatments and infection control and management
practices, and to share updated data internationally tominimize the spread of the novel coronavirus to protectorgan recipients and organ recipient candidates.

COVID-19-infected organ recipients
The COVID-19 Committee called for reports on individual
case histories of COVID-19-infected organ recipients intransplant facilities and enumerated the data to inform thepublic online (Table 1). The information has been updated
almost every day so that we can grasp the cumulative
number of infected patients among organ recipients andtrack their situation and movement in detail. This is helpful
not only for organ recipients but also for recipient
candidates, recipients’ families, and the public as it shows at
a glance how much organ recipients are in crisis. It also
shows how concerned parties can prepare and how others
can support them.
The data show that the number of infected recipients has
increased rapidly owing to the third wave (after the end of
September’s holidays). Kidney recipients are the major setof patients at risk because the number of kidney transplants
is highest. Recipients aged 50–59 years are the largest
number of infected recipients because the risk ofcontracting COVID-19 increases with age, but the age limit
on organ recipients is around 60–70 years, so those over 70
are rare, or represent recipients who received an organ
when they were younger. Male recipients have higher
infection rates than females because the ratio amongrecipients is around two males to every female. The numberof recipients who have recovered is lower than average,
because recipients are in treatment for longer, more
recipients retest positive, and the number of deaths ishigher than among healthy people in the general population(Raja et al., 2021).

Cutting-edge medical information
The COVID-19 Committee has encouraged registration ofrecipients infected with the novel coronavirus to follow up
such patients and to share data across the world to aid
development of countermeasure strategies. It also has
provided various web lecture presentations in PowerPoint
by transplant surgeons and transplant medical carespecialists to share the updated data. In addition, it has
started to deliver online videos about COVID-19 and organtransplant medical care for organ recipients, candidates,
families, and the public in clearly understandable terms.

fTraditional medicine
Okayama University and a health care company
collaborated on research to reduce immunosuppressing
drugs and blend Chinese caterpillar fungus (!"#$),

Table 1: Information submitted on COVID-19-infected
recipients

Note: Information on four patients in the “prognosis” was notavailable as unrecorded. Source: The number of organ recipients
infected with COVID-19. In: Japan Society for Transplantation[website] (https://square.umin.ac.jp/jst-covid-19/images/
20201221covid-19cases.pdf (updated 09/28/2020), accessed
09/28/2020).

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

Chronic organ failure patients
The category of chronic organ failure patients who are solidorgan recipients is a very high-risk group and contains two
sets of patients: recipients and retransplant recipients.
Recipients may have received all kinds of solid organs, suchas heart, liver, kidney, lung, pancreas (including
simultaneous pancreas and kidney transplantation),
pancreatic islet, and small intestine from brain-dead andheart-dead donors (deceased donors) or from living donors.
They received the organs between one year and more than
30 years ago, but the biological attachment rate of atransplanted organ is about 5–15 years on average. Some
recipients have survived for over 30 years and some evenover 40 years, but those who have survived longest havebeen taking immunosuppressant drugs for so long time that
their immune systems are damaged. So successful organ
recipients are also people at high risk of infection due totheir long-term use of immunosuppressant drugs.
The second set is re-transplant recipients of all kinds ofsolid organs (except the liver) from various combinations ofdonors (for example, receiving a irst organ from a living
donor and a second from a heart-dead donor). They are also
long-term immunosuppressant drugs users because they
took the drugs during both transplants, even if they had abreak from taking the drugs following the initial organ
rejection, therefore causing damage to their bodies,
meaning that they are also at high risk. There are also reretransplant recipients now and it is possible that there may
even be re-re-retransplant recipients in the near future,
although as far as I know this four-time transplantation has
not happened yet. However, Japan faces the most severe
chronic organ shortage, and other countries worldwide alsolack organ donations, so all recipient candidates are also atserious high risk during the COVID-19 pandemic. In
addition, the JST has called for various organ transplant
operations to be delayed—especially heart, liver, kidney,lung, pancreas, pancreatic islet, and small intestine fromboth brain-dead and heart-dead donors, and liver, kidney,
and lung from living donors. As a result, solid organ
recipient candidates must wait longer for organ donations
and the operation restart date is unclear. The number oforgan transplants dropped sharply worldwide during thecoronavirus pandemic: deceased donor organ transplants
dropped by 51.1% in the US and 90.6% in France compared
to before the pandemic, so Japanese recipient candidates
cannot rely on either national or overseas transplants
during the pandemic (Mokhtari et al., 2020).

eventually need a kidney transplant. Kidney failure patients
have a long wait for an organ donation while undergoing
dialysis due to the severe worldwide organ shortage.
There are two types of diabetes. Around 5% of diabetes
patients have type 1; their age at onset is under 14 years
and they need insulin replacement therapy. More than 95%
of diabetes have type 2; they tend to be middle-aged andelderly at onset. The big three complications of type 2
diabetes are disorders of nerve, eyes, and kidneys (diabetic
nephropathy). Diabetic nephropathy patients need dialysis
irst and then eventually a kidney transplant. Type 2
diabetes is a lifestyle-related illness. Type 2 patients tend tobe elderly: about half of dialysis patients who have diabetes
are over 70 years old and two thirds are over 65 years old.
Thus, dialysis users who are diabetes patients are mostly
elderly and are therefore at high risk of COVID-19.
Another risk to dialysis users is the facilities where theymust get dialysis therapy, such as hospitals and specialist
facilities, which are spaces at high risk of COVID-19 clusters.
Because most Japanese dialysis patients rely on blood
dialysis, the facilities involve many patients in a large room
where they must spend four hours per day, and they have tocommute there three times a week. According to theJapanese Society for Dialysis Therapy, 708 dialysis patients
have become infected with COVID-19 (JSDT, 2020). Bothdialysis users and their facilities are at high risk in Japan.

Chronic kidney disease patients
Another high-risk group is chronic kidney disease patients,
especially those who need dialysis to survive (Kliger et al.,2020). This section focuses on two categories of dialysis
user: diabetes patients and kidney recipient candidates,
including kidney retransplant patients. Most patients whoneed kidney transplants are diabetes patients and kidney
disorder patients whose original disease is kidney failure.
Diabetes patients are the majority; they have many
symptoms, but most have kidney damage, and will

Hospitals conducting
operations

f

f

188

Kidney transplant patients (from brain-dead donors)
Unfortunately, since the COVID-19 pandemic started, thenumber of organ transplant operations has decreased
across the world. Because organ transplantation itself is ahigh-risk medical procedure, with chances of infection fromorgan donation, organ replacement, and organ reception, alltransplantation procedures create many risks.
Figure 1: Organ transplant operations in hospitals in Japan
Hospitals that
postponed
operations

S o u r c e : D a t a f ro m : T h enumber of organ transplant
operations. In: Japan Society
for Transplantation [website](https://square.umin.ac.jp/
jst-covid-19/images/
report202006.pdf (updated
09/28/2020), accessed
09/28/2020).

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

f

f

f

f

f

f

The JST established basic guidelines concerning the
pandemic and called for organ transplant operations to bedelayed but not prohibited. However, every hospital has its
own guidelines, so some have performed organ transplant
as usual, some have reduced operations, and some havestopped organ transplants altogether. The great variability
among hospitals adds to the confusion for not only solidorgan recipient candidates but also living donors. Everykind of solid organ transplant carries several risks (at lower
or higher levels, but none are without risk) to both donors
and recipients, of course. Further, recipients are at risk thata donor (whether brain-dead or heart-dead) may have had
COVID-19; added to which, both recipient and donor are at
risk during a donation from a living donor. In addition, it isimportant to note that living donors also become people athigh risk after organ donation.
Let’s take kidney transplants from deceased donors(both brain-dead and heart-dead donors) as a case study.
Figure 1 shows a total of 72 hospital situations regarding
kidney transplant operations during the COVID-19
pandemic. Of these, 36 stopped kidney transplants fromdeceased donors but the other 36 conducted the operations
as normal.
The half of the hospitals that stopped kidney transplantsfrom deceased donors stated that they would do so until theend of the pandemic was declared (3 hospitals: 8%); until
the number of new COVID-19 infections in the prefecture
was zero (3 hospitals: 8%); until no further COVID-19
patients were present in the hospital (1 hospital: 3%); withno plan to perform organ transplant operation for a
temporary period (1 hospital: 3%); and/or for otherreasons (27 hospitals: 75%).
Another 50% of hospitals that did perform kidneytransplants from deceased donors stated that they would
continue to perform kidney transplant operations without
restriction (11 hospitals: 31%); only for those cases that
could not be postponed (6 hospitals: 17%); once they had
stopped and restarted transplant operations (15 hospitals:42%); and/or for other reasons (4 hospitals: 12%).
We can see that half the hospitals recognized that therisk of COVID-19 was greater than that of transplant
treatment during the pandemic; their attitudes are very
prudent. Another half assessed that the long delays fortransplant operations posed a much higher risk than
COVID-19 infection. As a result, 50% of kidney recipient
candidates received donated organs and had to take
immunosuppressant drugs, so they are battling infections,while 50% continue to wait for an organ transplant whileremaining on dialysis. The decision of whether to perform
transplant operations is a very dif icult one for transplant
surgeons, and nobody knows for certain which is better forrecipient candidates. However, this pandemic began in
March 2020, so if it lasts much longer, organ recipient
candidates will face the dilemma of whether they are more
likely to die from COVID-19 or from organ failure (Yuzawa,2020).
The situation with organ transplant operations varies
according to each hospital, each city, and each prefecture in

189

Japan. I asked one of my informants, who received a kidney
re-retransplant at a hospital in Osaka, about postponing
organ transplant operations. He said:
Stop or postpone organ transplant operations? You meannationwide? I’ve never heard that story. Organ transplant
operations have been conducted properly here. Is that right? I
think that organ transplant operations should be performed
because there are too few organ donations and there are somany recipient candidates waiting for organs who require
prompt action.
Elderly people in care homes (1)Elderly people are at high risk of COVID-19, as most people
know. In this section, I focus on elderly people who live incare homes. My mother lives in a care home in Sapporo,
Japan, which had to introduce several strategies during the
pandemic from February to October 2020. Care homes are
high-risk places because care workers are required to takecare of elderly people using close contact, and this isprecisely how COVID-19 is most commonly transmitted(Backhaus, 2017). Further, most elderly people in carehomes have some loss of motor function and/or dementia,
so it is dif icult to reduce the risk of spreading the virus
from care workers to residents (Lock, 2013). In addition,
care home workers usually provide close personal care, butduring the pandemic this results in signi icantly heightenedrisks for workers and residents. Sapporo entered the
pandemic earlier than other cities because it holds theinternational Sapporo Snow Festival in early February,which many people visit from all over the world—including
Wuhan, China. This festival led to the start of the COVID-19
pandemic and the governor declared a prefectural state of
emergency in February—the irst in Japan. Every care homeattempted to control the virus with various strategies.
My mother’s care home locked down in February, andmany unexpected problems occurred there, which have also
occurred in most care homes across the world• Elderly people were not allowed to go out, except tohospital appointments, so I could meet my mother when
taking her to hospital for her regular check-ups, but only
for the journey from care home to hospital and back. We
were prohibited from dropping in to do some shopping,have lunch, or drink coffee and chat. Also, I was notallowed to bring any food or drink for my mother to avoid
potential spread of the virus from outside the home.
• Elderly people were not allowed to see visitors, so mymother had no chance to meet her family, relatives, andcare manager. Thus, she could not maintain any private
human or business relationships except via telephone
calls and online meetings. Since many elderly people haveweak hearing and ind it dif icult to operate online
meetings, this is a major barrier.
• Elderly people had no recreation during the pandemic.
Usually, many outside events are held at care homes for
elderly people to help them enjoy a sense of the seasons,such as cherry blossom appreciation (in spring), Bon
festival dancing (in summer), and marking the changing
colors of autumn leaves. These beautiful seasonal events

190

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

recall elderly people’s happy youthful memories andstimulate their cognition function, but only inside eventsare permitted during the pandemic.
COVID-19 cluster: Sapporo, Japan
COVID-19 clusters in elderly homes happened regularly andhad serious results. The irst tragic cluster case was in April
2020 in a care home in Sapporo, where 92 elderly people
were resident and 17 died. This caused many people to pay
attention and think about the situation in elderly homes
carefully. In July 2020, there was a COVID-19 cluster in mymother’s care home. A care worker’s family member
became infected; the worker also became infected and gave
it to an elderly resident. All the residents got a free PCR test
and one person stayed in hospital, while all the otherresidents had a two-week quarantine inside their own
rooms, under the control of the local health authority.
Fortunately, there were no deaths.
Even in 2021, my mother’s care home still has a “novisiting” policy and only telephone calls are allowed, so I try
to call her every Saturday afternoon to chat and check on
her health condition. Her care manager also emails me toreport on her situation every month and sends me letters
including photos of my mother at inside events such as
Halloween and birthday parties, and occasional indoor
activities, as well as informing me about my mother and thecare home’s situation and future plans regarding the
COVID-19 pandemic. I live only ive minutes’ walk from mymother’s care home, but many residents’ families live muchfurther away, so many residents cannot see any family
members at all.
Almost every day, serious clusters are happening atelderly homes in Japan (indeed, all over the world). Over the
past year of the pandemic, it has become clear that not only
are older people at greater risk of infection; clusters at carehomes are also very serious high-risk events that need to be
avoided: it is vital to manage and control the wide diversityof risks for elderly people and their care homes.

ffElderly people in care homes (2)Another problem for elderly people in care homes is that
unexpected side-effects of being unable to meet with family
members during the COVID-19 pandemic have become
apparent since spring 2020. Elderly people who have beenquarantining from outsiders inside their care homes only
see care home workers—such as caregivers, social workers,
and medical doctors—and the friends they live with inside
the home. During this lockdown, many specialists have been
worried about residents losing both motor function andcognitive function without stimulation from the outside
world as a result of isolation and a lack of communication. I
would like to focus on their physical and mental health,including geriatric diseases and dementia, during thislockdown period. The Japan Geriatrics Society advised older
people to practice caution under COVID-19 restrictions (JGS,
2020a).
In March 2020, the Society’s Subcommittee on Frailty
and Sarcopenia cautioned against inactivity for elderly
people during the pandemic:

COVID-19, Practice Caution for Older People
We are deeply worried about the pandemic of the newcoronavirus infection around the world. It is so sad to hear
many people die due to COVID-19, especially older people
with comorbidities such as diabetes, cardiovascular disease,lung disease, etc., have a higher risk for mortality. It is ofcourse important for us to avoid the infection, but at thesame time we should avoid the secondary effect of selfrestraint due to the pandemic. Therefore, the Japan
Geriatrics Society decided to raise awareness of “preventionof frailty” during the pandemic. We are afraid that in somecities and countries going out might be strictly prohibited,
so you might have to change the contents of this poster
depending on the current situation of your community. We
do hope we can overcome this hard time by human wisdom.
A survey focusing on dementia research was conductedby Hiroshima University and the Japan Geriatrics Society,via the Japan Association of Geriatric Health Services
Facilities and the Japan Care Manager Association between
June and July (JAGHSF, 2020; JCMA, 2020). It found thatabout 40% of elderly Japanese people who suffer fromdementia have seen a worsening of their advanced
symptoms because of the long periods of isolation andanxiety in elderly people’s care homes as a result of thestay-at-home policy to protect them from COVID-19.
Dementia patients living in care homes have had less timeand opportunity to move their bodies (LS&MT, 2020). This
extremely serious phenomenon is affecting not only elderly
Japanese people with dementia in care homes but also
elderly people worldwide during the pandemic. What isworse, nobody knows when the pandemic will end, and thelonger the stay-at-home policy remains in place, the more
serious the situations will become for elderly residents ofcare homes. We also have to keep an eye on these elderly
people as they will continue to be at high risk in the future(British Geriatrics Society, 2020).
The Japan Geriatrics Society created material on how toprotect elderly people from the novel coronavirus andprevent frailty from developing and increasing, in order not
to diminish resistance among elderly people during the
COVID-19 pandemic. This was made available free of charge
on the Japan Geriatrics Society website to guide andenlighten not only elderly people but also their families andcarers (JGS, 2020b). The material offers useful tips for
elderly people to keep their bodies in good health andprotect them from being reduced to a bedridden state. It
also offers advice on how to delay the onset or progressionof dementia and improve elderly people’s quality of life. It
could also be relevant to other people at high risk such as
middle-aged people with severe diseases including diabetes,
heart disease, and cancer, as well as cigarette smokers. It is
not exclusively related to the pandemic but is always
relevant.
Conclusions
The three categories of people at high risk discussed in thispaper are organ recipients, recipient candidates, and elderly
people in care homes, all of whom struggled more inEubios Journal of Asian and International Bioethics 31(3) (March 2021)

f

f

f

summer than spring 2020 during the COVID-19 pandemic.
The summer was hotter, more humid, and longer due toclimate change, and people also had unexpected problems
such as heatstroke from wearing masks. Also, people weretired physically and mentally due to the stay-at-home policy
and were struggling with the pandemic and uncertainty
about the future for a long time, since nobody knows when
the situation will end.
Organ recipients (immunosuppressant drug users) are athigh risk of becoming infected with COVID-19, and their
death rate is higher. They face the serious dilemma ofchoosing between the risk of death from receiving an organ
and having to use immunosuppressant drugs and the risk ofdeath from organ failure. Organ transplant medical
treatment makes it very dif icult for the body to battle
infectious disease, especially during such a long pandemic.
Medical workers and researchers are trying to marryWestern cutting-edge medical technology and traditional
medicine such as Chinese herbal remedies (Kampo
medicines). Because rejection of a donated organ is anatural reaction of the body, recipients must take
immunosuppressant drugs, but this makes the risk of
becoming infected with the novel coronavirus much greater.
This is a great challenge for medical history during the
COVID-19 pandemic.
Recipient candidates and dialysis patients (thoseawaiting a kidney transplant) are having to wait longer thanusual as organ transplant operations have been delayed.
The numbers of operations have been reduced for all kindsof organs and all types of donors, both in Japan andworldwide, as an anti-COVID-19 measure, regardless of thenumber of donations. As a result, recipient candidates arehaving to remain on dialysis for longer while they wait, andtheir bodies are therefore becoming increasingly damaged.
Elderly people are at risk of being in a cluster of
infections and many people’s dementia has worsened due toisolation in homes. Many clusters occurred in care homes insummer 2020, and even now elderly people are unable togo out and interact with people outside the home, having
already spent a long time in lockdown thanks to thepandemic. While the stay-at-home policy has been helpful
as a strategy to combat infectious diseases, it has increased
the risk of worsening dementia by 40% as a result of a lackof activity (physical deconditioning) and lack ofcommunication (isolation).
These three categories of people at high risk of infection
have been battling with a number of dif iculties during thesummer, but the pandemic could be used to help to create
wider awareness of their experience. The policy of wearing
masks led to the risk of heatstroke during the summer.
Researchers are working on the problem of
immunosuppression—a major side effect of organtransplantation—by using traditional remedies like Kampo
medicines (Chinese herbs). More bioethical research is also
necessary to contribute to knowledge about these people’s
life issues.

191

References
Backhaus, P. (2017), Care Communication: Making a home in a Japaneseeldercare facility (London: Routledge)
British Geriatrics Society (2020), COVID-19: Managing the COVID-19
pandemic in care homes for older people, Good Practice Guide (4):1–8(London: British Geriatrics Society).
Caplan, A. and Coelho, D. (1999), The Ethics of Organ Transplants: The
current debate (Contemporary Issues) (Buffalo, NY: Prometheus Books).
CDC (2020), Centers for Disease Control and Prevention (CDC) [website](https://www.cdc.gov/, accessed 12/28/2020).
Chen, D., Yang, B., Zhang, Y., Chen, L., Wei, L., Zhang, W. et al. (2020),
Withdrawing mycophenolate mofetil in treating a young kidneytransplant recipient with COVID-19, Medicine, 99(24):e20481 (Wolters
Kluwer Health, Inc.).
Coates, P. T. (2020), A Kidney International “journal of the COVID-19 year”
in kidney transplantation, Kidney International 98(6):1404–1406(Elsevier, Inc., on behalf of the International Society of Nephrology).
Cooper, A. and Cooper, J. (2014), Staying Alive: Dialysis & kidney transplantsurvival stories (London: Rossendale Books).
Himmelfarb, J. and Ikizler, T. A. (2018), Chronic Kidney Disease, Dialysis, andTransplantation E-Book: A companion to Brenner and Rector’s The
Kidney (Philadelphia: Elsevier).
IOC (2020), International Olympic Committee (IOC) [website] (https://www.olympic.org/the-ioc, accessed 10/29/2020).
JAGHSF (2020), Japan Association of Geriatric Health Services Facilities[website] (http://www.roken.or.jp/kyokai/english.pdf, accessed
12/28/2020).
JCMA (2020), Japan Care Manager Association [website] (https://www.jcma.or.jp/, accessed 12/28/2020).
JGS (2020a), COVID-19, Practice Caution for Older People. In: Japan
Geriatrics Society [website] (https://www.jpn-geriat-soc.or.jp/en/
covid/, accessed 10/28/2020).
JGS (2020b), Japan Geriatrics Society [website] (https://www.jpn-geriatsoc.or.jp/en/, accessed 12/28/2020).
JSDT (2020), Japanese Society for Dialysis Therapy [website] (https://www.jsdt.or.jp/index_e.html, accessed 12/11/2020).
JST (2020), COVID-19 Committee. In: Japan Society for Transplantation[website] (https://square.umin.ac.jp/jst-covid-19/, accessed
09/27/2020).
Kaser, A. (2020), Genetic risk of severe COVID-19, New England Journal of
Medicine 383(16):1590–1591 (Waltham, MA: Massachusetts Medical
Society).
Kliger, S. A., Cozzolino, M., Jha, V., Harbert, G., Ikizler, T. A. (2020), Managing
the COVID-19 pandemic: international comparisons in dialysis patients,
Kidney International 98:12–16 (Elsevier Inc., on behalf of theInternational Society of Nephrology).
Lock, M. (2002), Twice Dead: Organ transplants and the reinvention of death(Berkeley: University of California Press).
Lock, M. (2013), Alzheimer Conundrum: Entanglements of dementia andaging (Princeton: Princeton University Press).
Loupy, A., Aubert, O., Reese, P. P., Bastien, O., Bayer, F., Jacquelinet, C. (2020),
Organ procurement and transplantation during the COVID19 pandemic,
Lancet 395:e95-e96.
LS&MT (2020), Stay home policy to curb COVID-19 cited for making
dementia worse (August 13, 2020). In: Life Science & Medical
Technology [website] (https://www.stof icetokyo.ch/news/life-sciencemedical-technology/stay-home-policy-to-curb-covid-19-cited-formaking-dementia, accessed 09/28/2020).
Matusmoto, Y. (2011), Faces of Aging: The lived experiences of the elderly inJapan (Stanford: Stanford University Press).
Mokhtari, T., Hassani, F., Ghaffari, N., Ebrahimi, B., Yarahmadi, A.,
Hassanzadeh, G. (2020), COVID-19 and multiorgan failure: A narrative
review on potential mechanisms, Journal of Molecular Histology
51(6):613–628 (Netherlands: Springer).
NHK (2020), Coronavirus chronology. In: NHK (Japan Broadcasting
Corporation) [website]. (https://www3.nhk.or.jp/news/special/coronavirus/chronology/, accessed 10/29/2020).
Raja, M. A., Mendoza, M. A., Villavicencio, A., Anjan, S., Reynolds, J. M.,
Kittipibil, V. et al. (2021), COVID-19 in solid organ transplant recipients:

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

A systematic review and meta-analysis of current literature,
Transplantation Reviews (Orlando, USA), 35(1):1–16 (Elsevier Public
Health Emergency Collection).
Scott, K. (2020), COVID-19 Fear, Safest Risk? Your anxiety, fear andinformation is killing you before the virus (Tokyo: Amazon Services
International, Inc.).
Yasuoka, K. (2019), Noushi Zokiishoku to mukiau tameni: Iryousha
Recipients Donor families heno kikitori tyousa kara (To Face Brain Deathand Organ Donation: Interview research from medical staff, recipient
donor families) (Kyoto, Japan: Koyo Shobo).
Yasuoka, K. (2020), Challenges for organ recipients and elderly persons
during the COVID-19 pandemic, Eubios Journal of Asian andInternational Bioethics 30(7):382–386 (Christchurch, New Zealand:
EJAIB).
Yokobori, S. (2020), Heatstroke management during the COVID-19
epidemic: Recommendations from the experts in Japan, Acute Medicine &Surgery 7:e560 (John Wiley & Sons Australia, Ltd on behalf of Japanese
Association for Acute Medicine).
Yuzawa, K. (2020), Establishment and evolution of “basic guidelines fortransplantation medicine against new coronavirus infections” by theJapan Society for Transplantation, Japanese Journal of Transplantation
55(2):77–83 (Tokyo, Japan: The Japan Society for Transplantation).
WHO (2020), Coronavirus disease (COVID-19) pandemic. In: World HealthOrganization [website] (https://www.who.int/emergencies/diseases/
novel-coronavirus-2019, accessed 10/29/2020).

Exploring researchers’ perceptions
on the consequences of publicationpressure to the research ecosystem- Angelina Patrick Olesen, Ph.D.
(Formerly) Pusat Citra UKM, Universiti Kebangsaan, Malaysia,
Bangi, 43600 Selangor, Malaysia
Email: patrick.angelina@gmail.com- Latifah Amin, Zurina Mahadi & Maznah Ibrahim
Pusat Citra UKM, Universiti Kebangsaan Malaysia,
43600 Bangi, Selangor
Malaysia.

Abstract

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The growing competition for limited research funding andacademic position, has pressured researchers into continuously
producing “publishable” results. This study aimed to investigate
researchers’ perceptions regarding the pressure to publish, and its
potential consequences to the research ecosystem. Based on
qualitative results obtained through series of in-depth interviews,
we found that publication pressures can potentially lead topositive and negative consequences to the ield of research. Our
indings found that publication pressure can potentially lead to theact of plagiarism, researchers resorting to unethical research
practices or non-scienti ic norm just to have a publishable paper aswell as resulted with a hostile working environment among
researchers as the need to compete become intense. Additionally,it also can motivate researchers to improve their writing andpublishing skills as their need to compete for academic positions,research funding, personal glory and future collaboration
increases. It is suggested that institutions of higher education need
to focus more on improving the writing, publishing and language
skills of the researchers besides creating awareness on theimportance of conducting research responsibly and ethically. At
the same time, focusing equally to researcher’s publication records
as well as their overall performance in teaching, supervising,community work and research activities.

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Keywords: publication pressure; research misconduct; responsible
conduct of research; personal glory; plagiarism

Introduction
One of the criteria for evaluating research projects is thequantity of papers authored by applicants. Such urgency
gives rise to the famous precept of ‘publish or perish’, whichbecame widespread throughout academia (Grieger, 2005).
The dissemination of this idea contributes towards
generating an evaluation policy utilized by most academic
institutions and funding agencies, based on how many
papers the researchers had published. Evaluating
researcher’s career performance based on the quantity of
publication indirectly has intensi ied competition among
researchers. Although, such competition is encouraged inscienti ically advanced countries because it increases theef iciency and productivity of researchers (Fellers, 1996), it
however, might con lict with their objectivity and integrity
because the success of a scienti ic paper partly depends on
its results and its contribution to the scienti ic community
as well as the society. Unfortunately, such competition
would attract the more ambitious academia that would
publish anything just for the sake of publishing even though
the publication is irrelevant to their ield of study (Huth,
1986). However, the absolute number of publications andauthorship order are only a few variables that institutions
may use in performance review and promotion. For
researchers in some countries, the pressure to publish inhigh impact journals is coupled with excessive instructional
workload, and with non-matching incentives structure to
reward the new expectation, it creates unnecessaryconsequences for the integrity of research (Anderson et al,2013). The progress of science is limited by the number of
positions and research funding (Goodstein, 2002),
researchers are ighting for fewer grants and the alreadyscarce top jobs in the academia (Dhand, 2002). Therefore, inorder to compete for these jobs, researchers must havefantastic publication records, and this could be the reason
why some researchers duplicate their publications to have abetter resume (Amin et al, 2012).
However, some researchers might disagree that pressure
to publish contributes to research misconduct. Pressure to
publish is aimed to encourage researchers to write andpublish their work in a high impact journal, and at the sametime, increase their productivity and enable them to share
their indings with other researchers from other countries.
At the same time, it creates a healthy and competitive
working environment, which can contribute to their successas researcher. According to Amin et al (2012), pressure canbe endemic source in a researcher’s life because as weknow, scienti ic work usually involves lots of pressure frommultiple commitments such as meeting, dateline, getting
sources of fund and anxiety in achieving project output.
Although, it might affect one’s decision to act ethically but,in the end, it is up to the individual judgment and values
that decide whether he/she acts against professional ethics
or not. This is because when people who are alreadymorally weak, ignorant, or insensitive are placed in stressful
situations, they might choose to engage in misconduct toEubios Journal of Asian and International Bioethics 31(3) (March 2021)
settle any con lict (Dhand, 2002). These arguments suggestthat the pressure to “publish or perish” may not necessarily
directly contribute to research misconduct but instead it isused as an excuse for some researcher to create ‘shortcut’for them to increase their publication records andstrengthen their resume for better career advancement.
Due to these arguments, we think that it is important to
conduct an empirical study among researchers who are
working within the research community in Malaysian
institutions of higher learning. A literature review reveals
few empirical studies focused on researcher in Malaysia inthe context of research misconduct issues and that they may
not cover many potentially relevant aspects. The provisionof academic misconduct such as plagiarism among
university students is the most frequently explored anddiscussed topic of misconduct in Malaysia (Smith, Ghazali &Minhad, 2007; Abdul Karim et al, 2009; Chun et al, 2012;
Wan et al, 2011; Yusof & Masrom, 2012; Wan Ali et al, 2012;
Bakhtiyari et al, 2014; Looi, Wong & Koh, 2015). However,study on the opinions and views of researchers in Malaysian
institution of higher learning regarding the factors
in luencing research misconduct are rarely highlighted andstill lacking. Therefore, the purpose of this study is to: 1)
investigate researchers’ views and perceptions on the“publish or perish culture” and whether it contributes toresearch misconduct, and 2) to bring attention to somespeci ic experiences and needs of researchers that focus on
issues related to publications.

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Methods
This study used in-depth, semi-structured interviews, with22 respondents. This provided opportunity for respondents
to share their experiences and perceptions on publicationpressure. Prior to the interview, rigorous discussion on thecurrent and potential issues regarding publication pressurethat has been highlighted in previous studies, was heldamong the researchers. Hence, the interview questionnaires
were developed based on the issues that are highlighted.
However, before deciding on the inal set of questionnaires,pilot testing was conducted to make sure that thesequestions will inally help us to achieve our objectives. The
answers to these interviews would indicate the participants’opinions on the issues related to the necessity to publish
and its role in researcher’s decision to engage in research
misconduct.
Participants
The participants were selected using purposive sampling
and then through a snowball method. We irst selectedparticipants among the academics in both public andprivate higher learning institutions, based on theirexperience in research ields, in terms of conducting
research and supervising research, and from there it
snowballs based on the suggestion of the respondents.
Overall, there are 22 respondents who voluntarily agreed toparticipate in this study. They come from different researchdisciplines, geographical areas, career levels and had yearsof experience in conducting and supervising research. There
were 9 males and 13 females; 6 of them were junior193

researchers with less than 10 years’ research experienceand 16 are senior researchers with more than 15 years of
research experience. The participants were from different
backgrounds including education, law, social sciences,
information technology, pure sciences, medicine,accounting, linguistics and engineering (Table 1).
Data collection
Initially, a set of interview questions together with theinformed consent forms, and a brief description regarding
the research including the objective were of sent via email
to the selected participants. When they agreed toparticipate and provide their consent by signing the consent
from, an agreed date and venue was decided, based on theavailability of the respondents. All the interviews wereconducted at the respondent’s workplace within theirrespective university. The interviews lasted between 45
minutes to 2.5 hours. The main language that was used forthe interview was English even though from time to time
Malay language was used. This series of interviews among
lasted four months (Jun 2018 to November 2018).
Data analysis
The interview transcripts were transcribed verbatim andanalysed using the ive stage framework approach. Stage 1
is familiarization, where investigators familiarize with thecontent of each interview, make notes and jot down any
topics that are signi icant or interesting. Stage 2 isconstructing a thematic framework, where investigators
review the list of topics and ideas that emerged in the irst
stage. These will become the initial thematic framework orcode an index of themes and sub-themes for the next stage.
Stage 3 is indexing and sorting. This stage may be time
consuming however, it made reading the labels easier, which
will be advantageous during the later stages of analysis
when constantly moving backwards and forwards acrossdata. Stage 4 is data summary and display, where theinvestigator constructs thematic charts for initial themes.
Finally, stage 5, mapping, and interpretation, where themain themes and sub-themes was developed. To avoid bias
on the data, all researchers are involved in the analysis anddecision on the inal indings as agreed by all researcher.
When no new themes or subthemes emerged, we
considered that the data reached a saturation level. It is
important to note that the opinions expressed by theparticipants involved in the study cannot be generalized tothe entire research community in Malaysia.
Results
Our study found that publication pressure is like a doubleedged sword where it can either lead to negative or positive
consequences. It can motivate and encourage researcher topublish their research or work, or it can encourage
researchers to engage in unethical research practices tomaximize publication numbers to ful il institution’s
requirements on publications.

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Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

Table 1: Demographic information of participantsNo.

GenderResearch
Experience(yrs)<10 years>25 years<10 years<10 years>20 years

Ethnicity

Expertise

Research training

Male
FemaleFemaleFemaleFemaleHigher Education
Institutions*(Local/Private)
Local
Local *
Local *
Local*
Local *

12
3
45

Foreigner
Malay Muslim
Malay
Malay
Ethnic Sarawak

AbroadLocal & abroad
Abroad
Local
Local

6
7
8
9
10
11
12
13
14
15

Female
Male
Male
Male
FemaleMale
Male
FemaleFemaleMale

Local *
Local *
Local *
Local *
Local
Local *
PrivateLocal *
Local*
Private<15 years>30 years>30 years>30 years<10 years<10 years>30 years>20years>30years<10 years

Malay
Malay
Malay
Malay
Malay
Malay
Foreigner
Malay
Malay
Malay

Education
Law
Health science
Bioethics
Conservation
geologyEngineering
Pure science
Philosophy
Pure science
Law
Bioethics
Pharmacology
IT
Law
Environmental
science16

Male

Local*<15 years

Malay

Mass
communication

Local & abroad

17
18
19
20
21
22

FemaleFemaleMale
FemaleFemaleFemaleLocal*
Local
Local
PrivatePrivateLocal *

>30 years>20 years>20 years>10 years>30 years>25 years

Malay
Ethnic Sarawak
Ethnic Sarawak
Foreigner
Malaysian
IndianPure science
Accounting
Linguistic
Health science
Medical Genetic
Medicine

AbroadAbroadAbroadAbroadAbroadAbroadf

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Publication pressure“University’s requirement for promotion among academic isgetting more stringent, and this can make some ‘people’quite desperate. With this ‘publish or perish’ culture,
academic are desperate to achieve the needed amount ofresearch publications because it all connected. You see, if a
researcher does not have any publication, he or she will not
get a research grant and without that, he/she can’t doresearch, which will limit their publication records. This
eventually delays their promotion or con irmation for apermanent post in the university and causes loss rather thangetting inancial rewards. So, some might be desperateenough to do whatever it takes to have his/her paper
publishes.” (Assoc. Prof., Law Faculty)
For another participant, “I believe... in a way, university’s
requirement to have certain number of publications, having
certain amount of research grants, having certain hours ofcommunity projects, teaching hours..and all otherrequirements do indirectly placing pressure on researcher.
This pressure sometimes is translated into inappropriate
research decisions.” (Senior Lecturer, Faculty of Science)
The need to publish frequently is becoming a pressure
when researchers do not have the necessary writing andpublishing skills and lack language competency. However,this can be improved through constant practice from anearly stage of researcher’s career path.
“Lack of writing skill and low command of English
language is not only among academician, but it is especiallyglaring among students, even at post graduate level. This

Local & abroad
AbroadAbroadAbroadLocal
Local
AbroadAbroadLocal & abroad
Localshows that we need to tackle this issue at the incredibly earlystage of research that is, I believe during their irst year as
graduate student. Yes, there is such courses, but we need toemphasize the importance of focusing and mastering theseskills rather than just telling them that they need to do it.
Plagiarism and authorship, the two misconduct that isalways associated with publication pressure can be avoided
if we can improve our writing and language skill. We need toequip our researcher and student with knowledge andtechnique of paraphrasing, restructuring, referencing etc.
Without these necessarily skills, publication pressure canpotentially lead to unethical decision.” (Senior Lecturer,
Faculty of Engineering)With or without publication pressure, the desire todisplay one own achievement for one own glory can verymuch lead to research misconduct. “It is to gain good
reputation among your peer in the same ield. When you
have quite several publications and because of that you
received huge research grant from a well known
internationally or locally organization, people willrecognize you as someone great. But when you do not haveany publication for quite a while, you are considered as
weak…or lazy…or stupid and your credibility as researcher
as well as academic is being question by the institution as
well as others. So, you know, this personal ‘glory’ is even abigger factor to involve in misconduct.”(Senior Lecturer,
Faculty of Engineering)Negative consequences of publication pressure
However, it cannot be denied that publication pressures dolead to negative consequences such as unethicalauthorship practices, and this include the emergence ofmany ‘free raider’ and ‘ghost writer’. “You know what theydo, it’s like they ‘joint-venture’ with other authors who I
presume their friends. So, as senior lecturer here of course
you know who is who, and who is expert in what area. If I
saw some name in a paper that is not her/his area
sometimes I will ask. Do they really have any knowledge inthat area? Can they teach in that subject? You know what
they answer…’takder la..nak hidup katakan’ (not really, justwant to survive). And this kind of answer really makes me
feel sad. They just put their name as co-author in any paper
although it is not really related to their ield of study just to
ful il the requirement to publish. I am not sure if this is
misconduct, but it is unethical practices if you ask me.”(Assoc Prof. Faculty of Law)
‘Free rider’ also resulted with several authors coauthoring one single paper, which is quite common in
medical or scienti ic ield but not in social sciences.
“Having more than ive or seven authors for one single
research articles is not uncommon in science or medical
ields but for social sciences, it is quite uncommon.
Particularly, in my area. I mean how many people you need
to for example, criticise on a ilm or book. I believe when
the university implement policy regarding publication
requirement, it do add on extra pressure on some. For me
it is no big deal but might not for others. I do not want to
say that this pressure will lead to misconduct but it does
indirectly play some role.” (Senior Lecturer, Faculty ofSocial Science)
Those who are already have con licted self-integrity may
ind it more dif icult to handle publication pressure.
Publishing in academic journal is a long-standing
requirement and expectation from all academics for ages
and whoever decide to join the academic ield should know
that. But now, the need for publishing as intensify andsome may ind it is impossible to ethically comply. “Ibelieve that it is a combination of pressure to perform inyour career, requirement from the university management
to publish research paper and our low value system within
our society. All these may lead to misconduct and not only
in research but in every aspect of our life.”

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Positive consequences of publication pressure
However, it is not all negative as pressure to publish canalso lead to positive consequences. It can become a positive
motivation for researchers to improve their writing andpublication skills and increase the desire to share theirindings and knowledge with other researcher globally.
“In my opinion, publication pressure has both positive andnegative effects on researcher’s actions. For those who into
research, the requirement to publish paper becomes some
sort of motivation for them, but I guess research andpublication is not for everyone even though we are
academics. It may not necessarily lead to misconduct, butsuch pressure can demotivate academician who genuinely

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Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

195

love to be in the academic due to their love for knowledge
sharing through lecturing.” (Lecturer, Faculty of Science)“Yes, I admit that the requirement to publish in high impact
journal is placing pressure on researcher/lecturer as well as
graduate students especially now when everyone is so
desperate to reach their KPI (Key Performing Index). But
then again, it all depends on the individual value of that
person. I feel that the requirement to publish can be a good
motivation for one to improve their performance in theirield instead of being an excuse to involve in misconduct.”(Assoc. Prof. Faculty of Accounting)Discussion
Our study found that publication pressure can both lead tonegative and positive consequences. Publication pressure
can negatively lead to some researcher to resort tounethical research practices and decisions to advance intheir research career. Competition for position in theacademic ield eventually creating pressure for researcher
to keep performing and publishing. Although by right,
researcher’s performance is best evaluated by their various
and different talent, but reality is, most university evaluate
researcher’s performance mostly on their publication
records. Too much focus on publication records eventuallycreating unhealthy competition among fellow researchers,
particularly when job promotion, con irmation, monetaryfunding, and research grant is largely depending on it. This
was also highlighted in Claxton’s article (2005) where hementioned that with publication records being so criticalto most scientists; it is not surprising that many exert great
effort to publish. Concerns have also been expressed thatscientists, particularly among medical scientists that they
are continuously producing publishable results and papers
at the expanse of quality, scienti ic rigor, and personal
integrity (Fanelli, 2010; Tijdink, Vergouwen & Smulders,2013).
Publication pressure can also lead to plagiarism. For
some participants in this study, pressure to constantly
publish research article can potentially lead to plagiarism
because for inexperience writer or simply who do not havethe passion to write, it might be dif icult for them toproduce an academically qualify writing that is
publishable. Frustration and pressure to meet theirperformance requirement, may lead some to plagiarize.
Although most empirical study on plagiarism normally
focused on students, there are some study that wereconducted among academics albeit limited. Based on study
conducted by Honig & Bedi (2012), they found that 25% of
paper, both empirical and non-empirical, presented at theInternational Management (IM) division of the 2009
annual meeting of the Academy Management by academic
scholars, has some amount of plagiarism and 13%
exhibited signi icant plagiarism. It is argued thatplagiarism by academic scholars occurred due to thegrowing pressure to publish research, as well as increasingpressure to publish in high impact top-tiers journal (Honig& Bedi, 2012).

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Unethical authorship practices are also highlighted as
one of negative consequences from publication pressure.
The ‘publish or perish’ mantra is thought to drive someinstances of unfair, honorary, authorship, particularly incountries of emerging scienti ic power (Gasparyan,
Ayvazyan & Kitas, 2013). This issue was also previously
highlighted by Claxton (2005) stating that the immersepressure to publish research, can potentially create
another issues, or concerns in scienti ic authorship such as
allocation of credits, coercion authorship, ‘ghost-writer’,admiration authorship and ordering of authorship.
Authorship dispute is not only about who get to be listed as
author in the article but also concerning the sequences of
the authors as credit given to the irst, second and so on
authors are different. This is because decisions aboutauthorship do affect careers and the views of society
toward science and scientists (Guraya et al, 2016)).
However, publication pressure is a positive motivation
for researchers to keep on publishing their researchoutcomes. Despite that some may face dif iculty inlanguage pro iciency or lack writing and publishing skills,
the desire to publish can motivate them to improve theirarea of weaknesses. The development of writing skills inacademia has been demonstrated not only to bene it thefaculty members but also the student they teach (Keen,2007). Realizing the need for improvement, researchers
are provided with multiple programs that aim to promote
publication output , including steps by steps guides andformal training program that involved multiple sections
over extended time frames with formal curriculum(Wilson, Sharrad, Rasmussen and Kernick, 2013).
Pressure to keep on publishing research indings canalso increase researcher’s desire to share and acquire
knowledge. When the article get published, particularly ina high impact journal, researcher is bound to have a feelingof accomplishment and for some, they have productively
contributing to knowledge sharing with others, and also
contributing to further development of knowledge within
their ield. This excitement may motivate them to continue
conducting research and publishing their positive or
negative indings. Knowledge sharing is considered to be
an important process of social interaction in organizations,and occurs at individual, group organizational levels (Vande Hoff et al, 2012; Razmerita, Kirchner & Nielsen, 2016).
In academic research, publishing research indings is one
way to how knowledge can be share among otherresearchers from around the globe.
Dealing with publication pressure and at the same time,trying to improve their lack of skills in writing andpublishing, teaches researchers how to handle thesepressures professionally and not to resort to unethicalpractices. It is argued that evident of misconduct throughretraction of publish paper showed that researchers withshorter publication history particularly early career
researchers are most likely to be the author of theretracted paper (Fanelli et al, 2015). It is an indication thatas researcher gain more experience and exposure in
research, they may deal with the pressures differently andthus, most likely to avoid decision that inclining tounethical research practices. The anecdotal evidence forthis is the observation that many of the cases involve
scientists at the start of their careers such as graduates
students, postdoctoral fellows, or scientist in their initial‘permanent’ job (Claxton, 2005). The junior scientists may
think that they may have to join the ‘race’ for publication as
they get the impression that it is the only way to survive
the competition (Guraya, 2016).
This boil down to the perception that researchers who
decided to engage in misconduct are normally instigate by
their own moral values, be it low or high moral values. For
one participant in this study, engaging in misconduct inresearch indicate that the researcher has low research
integrity thus when face with con licting situation they
have the tendency to go against the ethical norm inresearch. Requirement from the university do notnecessarily result with unethical research practices
instead, it can be a strong motivation to keep on writing
and improving for those who lack the skills. It is all
depending on the self -integrity of the individual
researcher. Based on Resnik’s Bad Apple Theory, individual
character plays an important role in research misconduct(Resnik, 2010). The theory explains that when individual
has low moral values and may have inancial problems or
psychological disturbance, then they are more prone tocommit an act of misconduct. It was argued that, despite all
the pressure posed on researchers, it is up to theindividual’s judgment to decide whether to go against
professional ethics or not (Amin et al, 2012).
In fact, there are various perceptions on the possible
factors that may lead researchers to engage in research
misconduct and publication pressure is named as one of it.
However, according to a study by Fanelli and colleagues(2015), the widely held belief that pressures to publish area major threat to scienti ic integrity was largely
contradicted by analyses at the level of country andindividual. Therefore, indicating that pressures to publish
produce different results for different countries andindividual with different values or priority. In addition, ego,job stress and expectations, organizational assessment
policies, plus other factors may tempt individuals to treadat the edge of unethical conduct (Lawrence, 2001;
Eysenbach, 2001). Additionally, it is argued by someparticipants in this study that scienti ic misconduct has
existed (Weistein, 1981; Awidi, 1982; Gar ield, 1990;
Brickley, 2002; Conner & Kitchen, 2002) even before thestress is placed on publication records.
There have been few suggestions on the possible
remedies to rectify the pressure to publish continuum inthe literature. One of the suggestions is to give lessweightage to the number of publications required foracademic promotions and tenure decision-making may
alleviate a consideration amount of faculty stress (Guraya,
2016). With less weightage place on publication records,
faculty member can now place more priority on innovative
teaching strategies and one on one consultation andguidance with the student, and this will result with better

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
faculty output. Another suggestion is to strengthen thenational policies against scienti ic misconduct (Fanelli et al,2015). At the same time, researchers should be encouraged
to improve their writing and publishing skills throughtraining workshop, seminar, or courses (Alberts, Hanson &Kelner, 2008). This can help them to gain knowledge about
writing and publishing as well as the ethical principles thatare applicable to research and writing. Hence, hopefully
deter them from engaging in misconduct for their bene itor others.
Overall, this study highlighted that pressures to publish
can produce positive or negative outcome for the researchcommunity. Some argued that pressures to publish canpotentially motivate some researchers to involve inresearch misconduct since eligibility for promotions,research funding, monetary rewards and recognition
largely depend on it. However, some choose to defer andargued that publication pressure can motivate researcher
to improve what they lack of in term of writing, andpublication and instigate the need to share and acquire
knowledge through publishing their indings. Decision to
engage in unethical research practices all go down to theindividual moral value and self-integrity.

3.

Conclusion
The results presented in this small-scale study suggest that
it is crucial that all parties in the research system pay more
attention to the issues and subjects related to research
misconduct and the pressure to publish. Although it isdebatable to say that the growing pressure to publish
research in high impact top-tiers journal contribute toresearch misconduct, it is also undeniable that one would
engage in misconduct just to increase their publication.
The ‘publish or perish’ culture creating a hostile and nonconducive working environment, and coupled with otherexternal factors including emphasize on personal glory,
language incompetency, inexperience in journal writing
skill, personal values, unethical authorship practices andinsuf icient monitoring, it may subsequently lead toirresponsible conduct of research. This highlighted thenecessity for greater lexibility when it comes to evaluating
researcher’s career development rather than justdepending on researcher’s publication records. Finally,
there is a need for more studies examining researchers’
perception on the roles of ‘publish or perish’ culture in theprevalence of research misconduct within the researchcommunity, and its implications on the researchcommunity as well as the society.

14.

Acknowledgements

24.

We would like to thank you all the participants for their time andviews for this study.

References

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2.

Abdul Karim, NS., Ahmad Zamzuri, NH & Muhammad Nor, Y. (2009).
Exploring the relationship between internet ethics in university
students and the big ive model of personality. Computers &Education, 53(1), 86-93
Alberts, B., Hanson, B. & Kelner, KL. (2008). Reviewing peer review.
Science, 321(5885), 15. Doi: 10.1126/science.1162115

f

1.

4.

5.
6.

7.
8.

9.
10.

11.

12.
13.

15.

16.

17.

18.

19.

20.
21.

22.
23.

25.

26.

197

Amin, L., Zainal, SZ., Hassan, Z. & Ibrahim, MH. (2012). Factor
contributing to research misconduct. The social sciences, 7(2),283-288
Anderson, MS. et al (2013). Research integrity and misconduct in theacademic profession. In. Paulsen, MB (ed.). Higher Education:
Handbook of theory and research 28. Springer Dordrecht
Heidelberg, New York. London
Awidi, AS. (1982). Piratism of scienti ic work. Acta Hematology, 67,
142-143
Bakhtiyari, K., Salehi, H., Embi, MA. et al (2004). Ethical andunethical method of plagiarism prevention in academic writing.
International Education Studies, 7(7), 52-62
Brickley, P. (2002). University science squads ferret out fraud.
Scientist, 16, 52-53
Chun, HQ., Stewart, N. & Wai, Cl. (2012). Attitudes of businessstudents toward plagiarism. Journal of Academic Ethics, 10(3),185-199
Claxton, LD. (2005). Scienti ic authorship. Part 2: History, recurringissues, practices and guidelines. Mutation Research, 589, 31-45
Corner, S. & Kitchen, L. (2002). Science’s most wanted: the top ten
book of outrageous innovators, deadly disasters and shocking
discoveries, Brasseys, Dulles, VA.
‘Dhand, R. (2002). Does research misconduct extent beyond
biomedicine? The COPE report 2002. Access at http://publicationethics.org/static/2002/2002pdf4.pdf
Eysenbach, G. (2001). Medical students see that academic
misconduct is common. British Medical Journal, 322(7297), 1307
Fanelli, D. (2010). Do pressures to publish increase Scienti ics’ bias?
An empirical support from US States data. PLoS One, 5(4):e10271
Fanelli, D., Costas, R. & Lariviere, V. (2015). Misconduct policies,
academic culture and career stage, not gender of pressures topublish, affect scienti ic integrity. PLoS One, 10(6):e0127556
Fellers, I. (1996). The determinants of research competitivenessamong universities. In. Teich, Ah (ed.). Competitiveness in academic
research. Washington: American Association for the Advancement of
Science, 35-72
Gar ield, E. (1982). More on the ethics of publication: abuses ofauthorship attributions and citation amnesia undermine the reward
system of science. Essays Inform. Scient. 5, 621-626
Gar ield, E. & Welljams-Dorof, A. (1990). The impact of fraudulent
research on the scienti ic literature. The Stephen E. Breuning case,
JAMA, 263, 1424-1426
Gasparyan, AY., Ayvazyan, L. & Kitas, GD. (2013). Authorshipproblems in scholarly journals: considerations for authors, peer
reviews and editors. Rheutomalogy International. DOI.10.1007/
s00296-012-2582-2
Goodstein, D. (2002). In the matter of J. Henkrik Schon (points ofview, Nov 2002). Access at:http//physicsweb.org/article/world/
15/11/2
Grieger, MCA. (2005). Authorship: An ethical dilemma of science. San
Paulo Medical Journal, 123(5), 242-246
Honig, B. & Bedi, A. (2012). The fox in the hen house. A criticalexamination of plagiarism among members of the Academy ofManagement. Academy of Management Learning and Education,
11(1), 101-123
Huth, EJ. (1986). Irresponsible authorship and wasteful publication.
Annal Internal Medicine, 104, 257-259
Lawrence, PA. (2001). Rank injustice: the misallocation of credit isendemic in science. Nature, 415, 819
Looi, LM., Wong, LX. & Koh, CC. (2015). Scienti ic misconduct
encountered by APAME journals: an online survey. Malaysian Journalof Pathology, 37(3), 213-218
Razmerita, L., Kirchner, K. & Nielsen, P. (2016). What factors
in luence knowledge sharing in organizations? A social dilemma
perspective of social medical communication. Journal of Knowledge
Management, 20(6), 1225-1246
Resnik, DB. (2010). What is ethics in research and why is it
important? National Institute of Environmental and Health Science

198
27.

28.

29.

30.

31.

32.
33.

34.

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
Smith, M., Ghazali, N. & Minhad, SFN. (2007). Attitudes towards
plagiarism among undergraduate accounting students: Malaysia
evidence. Asian Review of Accounting, 15(2), 122-146
Tijdink, JK., Verbeke, R. & Smulders, YM. (2014). Publicationpressure and scienti ic misconduct in medical scientists. Journal of
Empirical Research on Human Research Ethics, 9(5), 64-71
Van de Hoff, B., Schouten, AP. & Simonovski, S. (2012). “What one
feels and what one knows: the in luence of emotions on attitudes
and intentions toward knowledge sharing. Journal of Knowledge
Management, 16(1), 148-158
Wan Ali, WZ., Ismail, H. & Tan, TC. (2012). Plagiarism: To what extent
it is understood? Procedia-Social and behavioral science, 59,
604-611
Wan, R., Md Nordin, S., Halib, M. & Ghazali, Z. (2011). Plagiarism
among undergraduate students in an engineering-based university.
An explanatory analysis. European Journal of Social Science, 25(4),537-549
Weistein, D. (1981). Scienti ic fraud and scienti ic ethics. Conn. Med,45, 655-658
Wilson, A., Sharrad, S., Rasmussen, P. & Kernick, J. (2013). Publish or
perish: Ensuring longevity in nurse education-evaluation of astrategy to engage academics, students and clinicians in publication
activity. Journal of Professional Nursing, 29(4), 210-216
Yusof, DSM. & Masrom, UK. (2012). Malaysian students’
understanding of plagiarism. The International Journal-Language
Society and Culture. Access at http://www.educ.utas.edu.au/users/
tle/JOURNAL/

Crisis Self-Efficacy and Work
Commitment of Public School
Teachers during COVID-19
Pandemic- Erick T. Baloran- Jenny T. Hernan
University of Mindanao – Bansalan College, Bansalan, Davao delSur, Philippines
Email: erickbaloran.research@gmail.com

Abstract

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The COVID-19 pandemic has affected the public educational
sectors in terms of adjustment in educational modalities of
instructional delivery, school operations, and policies. With thisemerging paradigm shift, teachers' crisis self-ef icacy and workcommitment are relevant for research. This study's main
objective was to determine the signi icant in luence of crisis selfef icacy on the work commitment of public school teachers in
Region XI (Davao Region), Philippines, during the COVID-19
pandemic. The sample consisted of 1,340 public school teachers
across the Davao Region. The researchers collected the data
through adapted questionnaires contextualized to the local
setting and administered through online Google forms withappended consent. Mean, standard deviation, Pearson r, andregression analysis were used to analyze data. Results revealed
that crisis self-ef icacy signi icantly in luences the workcommitment of public school teachers during the COVID-19
pandemic. Uncertainty management during this crisis, inparticular, best predicts teachers’ work commitment. Data also
showed a high level of crisis self-ef icacy in terms of action,
preventive, achievement and uncertainty management, and highlevel of teachers’ work commitment in terms of commitment toschool, commitment to students, commitment to teaching, andcommitment to profession. Correlation results also showed a link

between crisis self-ef icacy and the work commitment of teachers
amid pandemic. Finally, the study concluded with practical
recommendations and directions for future research.
Keywords: crisis self-ef icacy, work commitment, education
workers, public schools, COVID-19 pandemic

1. Introduction
The COVID-19 pandemic has affected educational systems
worldwide, leading to the near-total closures of schools,
universities, and colleges. Most governments around theworld have temporarily closed educational institutions tocontain the spread of the virus. These nationwide closures
are impacting over 60% of the world's student population.
Several other countries have implemented localized
closures affecting millions of additional learners [38].
Studies on the impact of the COVID-19 pandemic wereconducted in the Philippines, which not just clearly
revealed strong reactions among students but also
discovered teachers' level of anxiety amid school closures.
However, Filipino teachers' positive outlook amid
psychological stress or anxiety was seen. Teachers indeed
had to face work and life changes during the pandemic
situation. Moreover, teachers face challenges with theonline-blended learning approach as they embrace the
new normal in teaching. Schools are still challenged to ill
the gaps in providing Information and Communication
Technology (ICT) resources and capacities of both teachersand students as they embrace the paradigm shift inpedagogical delivery [2] [25] [33]. Relatively, the workcommitment of the organization's employees in the midst
crisis like a pandemic may be affected. When an emergency
occurs within an organization, it usually disrupts daily
activities. It can generate fear of inancial loss, and its
impact to the organization could be immediate or longterm [26] [28].
In the school context, teachers' work commitment
during the COVID-19 crisis is important. Teachers needed
to abruptly transition their lessons from physicalclassrooms to distance learning platforms in response tothis crisis. Though they are struggling with many
challenges in their efforts to meet the development needsof their students, they remain committed to their learners'
education and emotional, social, cognitive, physical, andspiritual well-being. Stories abound teachers' concern for
their students' mental health, and other personal andacademic concerns [23] [24]. Furthermore, evidencebacked strategies are needed to help ensure teachers' wellbeing and maintain their commitment to work during the
COVID-19 pandemic. Teachers need to develop adaptability
in which they can adjust their thoughts, actions, andemotions to navigate new, changing, or uncertain
situations effectively. Since the teaching profession amid
crisis involves many unexpected situations and events,
teachers must respond to the changing needs of students
throughout a lesson, adapt to manage unexpected
situations relating to student behavior, and makeadjustments to their teaching plans when timetablechanges occur [7] [18]

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

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Besides, during a crisis like this, teachers must
demonstrate greater commitment to their job andconsequently increase their engagement at work [8] [9].
With or without a pandemic crisis, commitment is an
essential element of successful teaching. Showing
commitment to student learning, especially in thispandemic time can be an important factor in motivating
students to continue school. Committed teachers recognize
and endeavor to ful ill their responsibilities to theirstudents. The degree of loyalty of committed teachers have,toward their profession is one of their distinguishedcharacters. Teachers who are engaged in their profession
and committed to students and their learning play a crucialrole in the development of students [17]. One factor which
in luences the work commitment, especially during a crisis,
is the self-ef icacy beliefs. Employees with high ef icacy
beliefs perceive crises and dilemmas as challenges. They
are highly committed to the work tasks they carry out andinvest more time and effort into their work activities. They
also think strategically to resolve problems, recover easily
from predicaments, feel they are in control of the majorityof stressors and are less vulnerable to stress anddepression [5]. These concepts have led many researchers
to conclude that, in general, high levels of self-ef icacy
relate to positive and desired results [30] [32]. In
particular, crisis self-ef icacy is a predictor of individual
behavior in crises [27]. In the teachers' perspective,
teachers’ self-ef icacy beliefs are positively related to theircommitment to the teaching profession [6].
As Philippines combat against the COVID-19 pandemic,
the Department of Education (DepEd) started to brace forthe new normal in education amid the pandemic situationin the country. DepEd conducted a nationwide consultation
with stakeholders and education experts and prepared fora Learning Continuity Plan to deliver education to learners.
In preparation for School Year 2020-2021, DepEd will
provide Self-Learning Modules (SLMs) with the alternative
learning delivery modalities for various types of learners
across the Philippines, including modular, television-based,radio-based instruction, blended, and online. SLMs aredelivered in printed format to schools located in coastal
areas, far- lung provinces, and communities without accessto the internet or electricity. For households with gadgets
and devices, the department has announced that SLMs canalso be accessed online or of line. The department also
assured that teachers' safety and health will be its toppriority as SLMs can be done at home. Teachers who would
need to visit their schools to get materials to prepare theSLMs are required to follow the existing work arrangement
and health protocols [11]. With this existing scenario,
public school teachers indeed need to adapt to thisemerging shift in the paradigm of teachers. Teachers haveto adapt with the increasing demand of their workloads in
preparation for the opening of classes in the new normal
pedagogical setting. Hence, this situation calls for theircrisis self-ef icacy and, consequently, develops theircommitment to work and profession as educators.
Furthermore, the researchers had not come across of the

199

study that dealt with the in luence crisis self-ef icacy on
the work commitment of public school teachers during the
COVID-19 pandemic in the local setting. In this context, theresearchers were interested in determining the domain ofcrisis self-ef icacy, which signi icantly predicts the workcommitment of public school teachers in Region XI,
Philippines. This study can raise concern to bene iciaries ofthis study and possibly develop action plans to improveteachers' self-ef icacy and consequently augment theirwork commitment during a crisis such as a pandemic, thus,
the need to conduct this study. The following research
objectives guide this study: describe the level of crisis selfef icacy of public school teachers in terms of action,
preventive, achievement, and uncertainty management;
ascertain the level of work commitment of public school
teachers during the COVID-19 pandemic in terms
commitment to school, commitment to students,
commitment to teaching, and commitment to profession;
determine the signi icance of the relationship between thecrisis self-ef icacy and work commitment of public school
teachers during COVID-19 pandemic, and determine thedomain of crisis self-ef icacy which best predicts teachers’
work commitment.
2. Methods
Quantitative, non-experimental design of research using
the correlational technique was used in this study since it
aimed to determine the signi icant relationship between
the crisis self-ef icacy and work commitment of publicschool teachers during the COVID-19 pandemic. The venueof the study was in Region XI, located in Mindanao,
Philippines. The region is composed of ive provinces,namely: Davao del Sur, Davao Oriental, Davao del Norte,
Davao de Oro and Davao Occidental with six cities namely:
Davao City, Digos City, Tagum City, Panabo City, Mati Cityand the Island Garden City of Samal. An online survey
developed through Google forms with an appended
consent form was conducted from May 30 – June 11, 2020.
During this period, the Philippines experienced the irst
wave of sustained community transmission, and provinces
in Davao Region were under General and Enhanced
Community Quarantine set by the local governments. The
Snowball technique was used to determine the teacher
respondents who had access to the internet. The Survey
link was disseminated to various public school divisions
both in the elementary and secondary levels. Adaptedsurvey questionnaires were used for crisis self-ef icacy[26] and work commitment [34]. They were modi ied tosuit the purpose of the study, especially during the
COVID-19 pandemic period. A total of 1,340 public school
teachers across the region responded in the online survey.
Data were analyzed using mean, standard deviation,
Pearson r, and regression analysis as statistical tools tointerpret the collated data. The following range of means
with its descriptions was used: 1.00 – 1.79 (Very Low);
1.80 – 2.59 (Low); 2.60 – 3.39 (Moderate); 3.40 – 4.19
(High); 4.20 – 5.00 (Very High). The corresponding
interpretation for each range starts from never to rarely,Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

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Table 1: Level of Crisis Self-Ef icacy and Work
Commitment of Public School Teachers in Region XI,
Philippines during COVID-19 Pandemic
Variables/
Standard Mean Descriptix̅ve Level
Indicators
Deviation
3.87
high
Crisis Self0.681
Efficacy
Action
0.819
3.94
high
Preventive
0.722
3.91
high
Achievement
0.766
3.85
high
Uncertainty
0.751
3.76
high
Management
W
o
r
k
0.568
3.97
high
Commitment
Commitment to
0.688
4.06
high
schoolCommitment to
0.708
4.23
very highstudents
Commitment to
0.687
4.17
high
teaching
Commitment to
0.472
3.40
high
profession
As the data shows, teachers are committed to ful illing
their functions and proactively implement the educational
policies of the Department of Education (DepEd) during
the COVID-19 pandemic. They feel committed and obliged
to ensure academic success and continuous learning ofstudents amid the health crisis through varied ways suchas distance learning, blended learning, home-basedlearning, etc. To cope with these current problems anddilemmas brought by the pandemic crisis, teachers remain
to be goal-oriented by planning and strategizing a lexible
mode of instructional delivery. Also, teachers professedthat despite the new normal condition in school, they still
feel enjoyed and committed to their profession. They feelengaged in ful illing the teaching mission despite thechallenging changes in the paradigm of teaching amid the
COVID-19 crisis. In support, education during the
pandemic is not an easy task. Teachers need to facecontinuous changes in educational needs such as pedagogy,
curriculum, and regulatory educational policies. Sinceteachers are facing challenges [16], they should invest
more effort and involvement in maintaining and promoting
high-quality teaching and optimizing student outcomes[10]. The level of effort and involvement exerted by theteachers in pursuit for quality of teaching are re lected bytheir continued commitment to work, school, students, andf

3. Results and discussion
Examining the data in descriptive table 1 on the levels of
the crisis self-ef icacy and work motivation of public school
teachers during COVID-19 pandemic, it could be noted thatthe standard deviation of the mean scores ranged from
0.472 to 0.891 which are all below 1.0, the typical standard
deviation for a 5 point Likert scale. This indicates theconsistency of responses.
Data revealed that the high level of crisis self-ef icacy of
public school teachers during COVID-19 pandemic (x̅ = 3.7;
SD = 0.681) among public schools in Region XI, Philippines(Table 1) is the result of the high mean rating of its
indicators: action, preventive, achievement, anduncertainty management ranging from 3.76 to 3.94 asevaluated by the teacher respondents. High level meansthat the crisis self-ef icacy of public school teachers during
the COVID-19 pandemic is oftentimes manifested.
Further, data implies that teachers take the necessary
action to protect them at work during the COVID-19 crisis.
They also use their knowledge and personal and work
resources to prevent problems brought about by the
pandemic effectively. Amid the health crisis, public school
teachers still set to accomplish individual and work-related
goals, especially facing tasks and responsibilities upon
implementing distance and blended learning modalities inteaching. Fortunately, teachers during the COVID-19 crisis
can manage uncertainties effectively. They feel con ident
and resourceful in handling unforeseen and unexpecteddemands at work. As professed by one author [27], crisis
self-ef icacy enables crisis organizational members andleaders to develop more effective message strategies toprotect everyone and minimize crisis damage. Besides,
another study [14] mentioned that having a high level ofaction ef icacy could help prevent employees fromadditional or unnecessary harm. One research inding [21]also argued that enough information and resources as partof preventive ef icacy lead to certainty in crisis. Employeeswith higher levels of certainty are likely to be prevented
from more dangerous situations during an emergency.
When facing a current crisis, employees need to constitutedesirable work goals and increase self-belief that they
could stick to and achieve goals during the crisis [26].
Moreover, several authors [22] [29] [37] stated thatmanaging uncertainty is essential for crisis management.
Moreover, the overall high level of work commitment ofpublic school teachers during COVID-19 pandemic (x̅ =3.97; SD = 0.568), as re lected in Table 1, is the result of thehigh mean scores of its indicators: commitment to school,fcommitment to teaching, and commitment to profession,
with mean scores ranging from 3.40 to 4.17 and only one
very high rating (x̅ = 4.23) of the indicator commitment to
students. The high level of work commitment of publicschool teachers during the COVID-19 pandemic is anindication that teachers among public schools in the region
maintained a strong commitment to delivering quality
education for students despite the health crisis thecommunity is facing.

fsometimes, oftentimes, and always manifested for every
item in the questionnaire. The researchers personallyadministered the collection of data. Data collection was
done after proper permission was sought from theconcerned authorities and entities. Encoding, tabulation,and data analysis were thoroughly done to assure thequality of the entire study. Ethics was thoroughly observedin the study's conduct, considering the respondent's
participation in the online survey was voluntary.

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200

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)
to profession [12] [35]. Furthermore, commitment to
students motivates teachers to deal with students
undergoing personal crises or to be more sensitive andaware of student development and their achievement [13][15]. Also, teachers' commitment to teaching is re lected
through their willingness to exert effort in providing
effective instruction and devote extra time to students [36].
Likewise, teachers who are highly committed to their201

school are expected to engage in school tasks to achieve
the school goals despite the existing circumstances [31].
According to some authors [20], employees need to choose
to redirect their emotional energies toward the profession
to which they belong despite work conditions. Generally,
during a crisis, teachers must demonstrate a moresigni icant commitment to their job and consequently
increase their engagement at work [8] [9].

Table 2: Signi icance on the Relationship between the Crisis Self-Ef icacy and Work Commitment of Public School
Teachers in Region XI, Philippines during COVID-19 Pandemic **. Correlation is signi icant at the 0.01 level
Work
Commitment
Crisis Self-Efficacy
Commitment
Commitment
Commitment Commitment
Overallto School
to Students
to Teachingto Profession.513**.435**.451**.346**.499**
Action(.000)(.000)(.000)(.000)(.000).548**.485**.530**.402**.561**
Preventive(.000)(.000)(.000)(.000)(.000).560**.493**.524**.342**.552**
Achievement(.000)(.000)(.000)(.000)(.000).582**.520**.559**.368**.584**
Uncertainty Management(.000)(.000)(.000)(.000)(.000).618**.542**.578**.408**.615**Overall(.000)(.000)(.000)(.000)(.000)
Table 3: Regression Analysis on the In luence of Crisis Self-Ef icacy on the Work Commitment of Public School
Teachers in Region XI, Philippines during COVID-19 Pandemic
Work Commitmentβ(Standardized
Coefficients)

B(Unstandardized
Coefficients)

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is signi icantly linked to teachers’ work commitment
during a pandemic. Further, it concludes that public school
teachers display a high level of commitment at work in the
COVID-19 crisis due to their high level of crisis self-ef icacy.
Teachers maintain high ef icacy beliefs that recognize crisis
as part of their work dilemmas and are highly committed
to ful illing work tasks at school, especially to theirlearners’ education. It con irmed the proposition of various
authors [30] [32] that work commitment, especially during
a crisis, is linked with self-ef icacy beliefs. Employees withhigh ef icacy beliefs, who perceive crises and dilemmas aschallenges, are highly committed to the work tasks they
carry out.

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One important purpose of this study was to determine
whether or not crisis self-ef icacy has a signi icant
relationship with public school teachers' workcommitment during the COVID-19 pandemic. As shown intable 2, the overall r-value on the correlation between thelevel of crisis self-ef icacy and the level of workcommitment of public school teachers during COVID-19
pandemic is .615 with the p < 0.01 which means that there
is a signi icant relationship between the two variables, thus
rejecting the null hypothesis. Generally, the correlation
between the two variables revealed a signi icant
relationship between the crisis self-ef icacy and the workcommitment of public school teachers during the
COVID-19 pandemic. It implies that the crisis self-ef icacy

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2.363
4.785
3.792
6.529

p-value

0.082
0.192
0.146
0.266

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0.057
0.151
0.109
0.202
0.620
0.384
208.490.000

TActionPreventive
Achievement
Uncertainty Management
R
R2
F
Overall p-value

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Crisis Self-Efficacy

0.018
0.000
0.000
0.000

202

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

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In addition, data shown in Table 3 is the regression
coef icients to test the signi icant in luence of the overall
crisis self-ef icacy on the work commitment of publicschool teachers during the COVID-19 pandemic. Using theregression analysis, the data revealed that teachers' overall
crisis self-ef icacy signi icantly in luences their workcommitment during the COVID-19 pandemic since
statistical data showed has the F value 208.49 and p < 0.01.
Hence, it signi ies the rejection of null hypothesis. The R2
value of .384 implies that their crisis self-ef icacy
in luenced 38.40% of the variance of work commitment ofpublic school teachers during the COVID-19 pandemic. In
comparison, the remaining 61.60% was attributed to otherfactors. Speci ically, in their singular capacities, thedomains of teachers’ crisis self-ef icacy such as preventive(T=4.785; p < 0.01), achievement (T=3.792; p < 0.01), anduncertainty management (T=6.529; p < 0.01) have asigni icant in luence on their work commitment during the
COVID-19 pandemic. On the other hand, the domain action(T=2.363; p=0.018) can still in luence teachers’ workcommitment but with the support of other domains.
Furthermore, among the domains of teachers' crisis selfef icacy, uncertainty management is the best predictor of
their work commitment during COVID-19 pandemic in its
singular capacity based on the standardized beta
coef icients (β=.266).
The data revealed that the overall crisis self-ef icacy
signi icantly in luences the work commitment of publicschool teachers during the COVID-19 pandemic. It af irmed
the proposition [8] self-ef icacy beliefs under any
circumstances in luence work commitment. In conjunction,
the inding of this study substantiated the study [6], which
pointed out that teachers' self-ef icacy beliefs in luence
their commitment to the teaching profession. Moreover,among the four domains of teachers' crisis self-ef icacy, theuncertainty management domain is the best predictor ofteachers' work commitment during the COVID-19
pandemic in its singular capacity based on thestandardized beta coef icients. It implies that teachers'
ability to manage or reduce uncertainties at work and inteaching during the COVID-19 crisis contributes to theirhigh commitment to providing continuous and quality
education for students. They are still committed toachieving school and professional goals despite the crisis.
They feel capable of controlling and adjusting with theunforeseen or unexpected changes in work conditions,especially in the aspect of pedagogy. In connection withthis inding, a related study [26] stated that managing
uncertainty is essential for crisis management. Crisis
management must minimize uncertainty before a crisis
occurs as well as manage uncertainties that emerge during
a crisis. Considering that uncertainty management ef icacy
re lects one's beliefs about the ability to deal withuncertainty in crises, reducing the amount of uncertainty
before a crisis occurs would result in a higher level of
uncertainty management ef icacy among employees, andthus contributing to higher work commitment.

4. Conclusion and recommendations
In today’s world health condition where the teachers in the
public educational sectors are challenged in terms ofadjusting with the paradigm shift of teaching and learning
process, improving crisis self-ef icacy is essential for
maintaining and augmenting teachers' commitment atwork. Results revealed that crisis self-ef icacy signi icantly
in luences the work commitment of public school teachers
during the COVID-19 pandemic. Uncertainty management,in particular, best predicts teachers' work commitment
during this crisis. Teachers' high ef icacy belief in
effectively managing unforeseen circumstances at work
caused by the pandemic is a predictor of their highcommitment to ful il their professional and pedagogical
functions and responsibilities in school.
Further, results speci ically revealed a high level of crisis
self-ef icacy in terms of action, preventive, achievement
and uncertainty management, and high level of workcommitment of public school teachers during COVID-19
pandemic in terms of commitment to school, commitment
to students, commitment to teaching, and commitment toprofession. Correlation results also showed a link between
crisis self-ef icacy and the work commitment of teachers
amid pandemic. In this study, a clear picture is establishedon the role of self-ef icacy of work employees who deem
themselves as capable of managing crises resulting inmaintaining and supporting work commitment. Also, thisstudy vividly emphasized the importance of teachers’ workcommitment during the COVID-19 crisis. With theimmediate transition at work, such as shifting fromphysical classroom contact to distance and online, blended
modality, teachers need to remain committed to delivering
accessible and quality education for all learners across thecultural, social, economic, and geographical backgrounds.
As the results showed that uncertainty management incrisis self-ef icacy is a signi icant predictor of teachers'commitment at work during COVID-19 pandemic, theresearchers highly recommend for the Department of
Education to initiate programs which focus on improving
the uncertainty management skills of its human resources
especially the teachers when facing a crisis in thecommunity and at work. Teachers should be trained on
how to be agile and adaptive to unexpected changes inwork settings. This can be done at the school community
level with the help and support of school administratorsand colleagues. Various school-based activities andestablished resiliency systems and practices can beorganized to develop teachers' strategies in making
themselves change-proof. With these, teachers can also
effectively cope with school organizational uncertainty andthe personal upheaval that it causes during any crisis, suchas the COVID-19 pandemic.
Moreover, as teachers face structural uncertainty amid
pandemic or any present calamities such as in the areateaching and technological change, and the rapidlychanging nature of work, it is recommended for DepEd tobegin to retool teachers with the new modalities for school
operations and instruction. It is also recommended that theEubios Journal of Asian and International Bioethics 31(3) (March 2021)
Department train school administrators and teachers on
how to reduce organizational uncertainties during a crisis.
School employees need to increase their motivation to
reduce uncertainty in the workplace when confronting
risky social situations. Teachers, in particular, should adapt
overt and covert techniques to mitigate certain types oforganizational uncertainty. In these times of signi icant
change in the educational set-up brought by the COVID-19
p a n d e m i c , D e p Ed s h o u l d i m p rove i n fo r m a t i o ndissemination, awareness campaign, and policy
implementation to decrease uncertainty levels of teachersamong schools. The researchers also recommend for every
school leader in helping teachers reinvent theirprofessional commitment by providing mental andpsychological interventions to reduce possible
psychosocial morbidity experienced by teachers, especiallyduring the period of sustained community quarantine.
School-level activities may be organized to fortify teachers'commitment to choosing the teaching profession andmaintain pride and engagement in ful illing the mission of
their job despite the challenging changes in the paradigmof teaching with or without the COVID-19 crisis.
Moreover, since the study stated the signi icant
relationship between the crisis self-ef icacy and work
motivation of public school teachers during the COVID-19
pandemic, it is highly recommended that teachers takepreventive actions at work by augmenting their knowledge
and personal and job resources. With this, teachers caneffectively attain the department's educational targets
despite work uncertainties, especially in implementing
distance and blended learning modalities in teaching
during the COVID-19 crisis. Schools can improve teachers’
crisis self-ef icacy by developing more effective message
strategies to safeguard teachers, parents, students, andstakeholders and minimize the risks of COVID-19 in the
educational system. Lastly, the researchers would like tosuggest to future researchers that a similar study with amore signi icant number of samples may be conducted inanother venue to con irm the elimination of the results as
generated in this study.
Acknowledgments
Data of this study were collected with the assistance of the
Planning and Research Unit of the Department of Education(DepEd) – Davao de Oro and other divisions in Davao Region,
Philippines. We thank all DepEd personnel for cooperating in thispersonally funded research.

References

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f

1.Ashford, J. B., & LeCroy, C. W. (2010). Human behavior in the social
environment: A multidimensional perspective (4th ed.). CA: Wadsworth,
Cengage Learning.
2.Baloran, E.T. (2020). Knowledge, attitudes, anxiety, and coping
strategies of students during COVID-19 pandemic, Journal of Loss andTrauma, DOI: 10.1080/15325024.2020.1769300.
3.Bandura, A. (1977). Self-ef icacy: The exercise of control. New York, NY:
W. H. Freeman and Company.
4.Bandura, A. (1986). Social foundations of thought and action.
Englewood Cliffs, NJ: Prentice-Hall.

203

5.Bandura, A. (2008). Social cognitive theory. In W. Donsbach, (Ed.)
International encyclopedia of communication (Vol. 10, pp. 4654-4659).
Oxford, UK: Blackwell.
6.Chesnut, S., & Burley, H. (2015). Self-ef icacy as a predictor ofcommitment to the teaching profession: A meta-analysis. Educational
Research Review, 15, 1-16.
7.Collie, R. J., & Martin, A. J. (2016). Adaptability: An important capacity
for effective teachers. Educational Practice and Theory, 38(1), 27-39.
8.Collie, R. J., & Martin, A. J. (2017). Teachers' sense of adaptability:
Examining links with perceived autonomy support, teachers'
psychological functioning, and students' numeracy achievement. Learning
and Individual Differences, 55, 29-39.
9.Collie, R. J., Martin, A.J. & Granziera, H. (2018, May 8). Being able toadapt in the classroom improves teachers’ well-being. The Conversation.
Retrieved from https://theconversation.com/being-able-to-adapt-in-theclassroom-improves-teachers-well-being-9578.
10.Darling-Hammond, L., & McLaughlin, M. W. (1995). Policies that
support professional development in an era of reform. PhiDelta Kappan,76, 597-604.
11.Department of Education (2020). DepEd prepares Self-Learning
Modules for education’s new normal. Retrieved from https://www.deped.gov.ph/2020/07/02/deped-prepares-self-learning-modulesfor-educations-new-normal/.
12.Firestone, W. A. (1996). Images of teaching and proposals for reform: A
comparison of ideas from cognitive and organizational research.
Educational Administration Quarterly, 32, 209-235.
13.Firestone, W. A., & Pennell, J. R. (1993). Teacher commitment, working
conditions, and differential incentive policies. Review of Educational
Research, 63, 489-525.
14.Frisby, B. N., Veil, S. R., & Sellnow, T. L. (2014). Instructional messages
during health-related crises: Essential content for self-protection. HealthCommunication, 29, 347-354.
15.Louis, K. S. (1998). Effects of teacher quality of work life in secondary
schools on commitment and sense of ef icacy. School Effectiveness andSchool Improvement, 9, 1-27.
16.Louis, K. S., & Smith, B. (1990). Teacher working conditions. In P. Reyes(Ed.), Teachers and their workplace: Commitment, performance andproductivity (pp. 23-47). Newbury Park, CA: SAGE.
17.Mart, C. T. (2013). A passionate teacher: Teacher commitment anddedication to student learning. International Journal of Academic
Research in Progressive Education and Development, 2(1), 437-442.
18.Martin, A. J., Nejad, H., Colmar, S., & Liem, G. A. D. (2012). Adaptability:
Conceptual and empirical perspectives on responses to change, novelty
and uncertainty. Journal of Psychologists and Counsellors in Schools,
22(1), 58-81.
19.Meyer, J. P., & Herscovitch, L. (2001). Commitment in the workplace:
Toward a general model. Human Resources Review, 11(3), 299-326.
doi:10.1016/s1053-4822(00)00053-x.
20.Meyer, J. P., Allen, N. J., & Topolnytsky, L. (1998). Commitment in achanging world of work. Canadian Psychology/Psychologie Canadienne,
39, 83-93.
21.Moynihan, D. P. (2008). Learning under uncertainty: Networks in crisis
management. Public Administration Review, 68(2), 350-365.
22.Murphy, P. (1996). Chaos theory as a model for managing issues andcrises. Public Relations Review, 22, 95-113.
23.Olson, K. (2020, May 7). Tips for teachers in a pandemic. Retrieved
from https://www.redlands.edu/bulldog-blog/2020/april-2020/tips-forteachers-in-a-pandemic/.
24.O’Sullivan, M. (2020, May 1). What about teachers’ learning during
COVID-19? Retrieved from https://www.wise-qatar.org/what-aboutteachers-learning-during-covid-19/.
25.Pan, H. (2020). A glimpse of university students’ family life amidst the
COVID-19 virus. Journal of Loss and Trauma, 1 –4. https://doi.org/
10.1080/15325024.2020.1750194.
26.Paraskevas, A. (2006). Crisis management or crisis response system?
Management Decision, 44 (7), 892-907.
27.Park, S. (2016). Development and validation of a crisis self-ef icacy
scale. Retrieved from https://trace.tennessee.edu/utk_graddiss/3661.
28.Ren, C. (2000).Understanding and managing the dynamics of linked
crisis events. Disaster Prevention and Management, 9(1), 12-17.

204

Eubios Journal of Asian and International Bioethics 31(3) (March 2021)

29.Reynolds, B., & Seeger, M. W. (2005). Crisis and emergency risk
communication as an integrative model. Journal of HealthCommunication, 10, 43-55.
30.Salanova, M., Schaufeli, W.B., Xanthopoulou, D., & Bakker, A. (2009). The
gain spiral of resources and work engagement. In A. Bakker & M. Leiter(Eds.) Work engagement: recent developments in theory and research.
New York: Psychology Press.
31.Somech, A., & Bogler, R. (2002). Antecedents and consequences ofteacher organizational and professional commitment. Educational
Administration Quarterly, 38, 555-577.
32.Stajkovic, A., & Luthans, F. (1998). Self-ef icacy and work-related
performance: a meta-analysis. Psychological Bulletin, 124, 240-261.
33.Talidong, K.J.B., & Toquero, C.M.D. (2020). Philippine teachers’
practices to deal with anxiety amid COVID-19. Journal of Loss andTrauma, DOI: 10.1080/15325024.2020.1759225.
34.Thien, L.M., Razak, N.A., & Ramayah, T. (2014). Validating Teacher
Commitment Scale Using a Malaysian Sample. SAGE Open, 1-9. DOI:
10.1177/2158244014536744.
35.Tsui, K. T., & Cheng, Y. C. (1999). School organisational health andteacher commitment: A contingency study with multi-level analysis.
Educational Research and Evaluation, 5, 249-268.
36.Tyree, A. K. (1996). Conceptualising and measuring commitment tohigh school teaching. Journal of Educational Research, 89, 295-304.
37.Ulmer, R. R., Seeger, M. W., & Sellnow, T. L. (2007). Post-crisis
communication and renewal: Expanding the parameters of post-crisis
discourse. Public Relations Review, 33, 130-134.
38.UNESCO (2020). Education: From disruption to recovery. Retrieved
from https://en.unesco.org/covid19/educationresponse.

Chief Editor: Darryl R.J. Macer
Associate Editor: Nader Ghotbi
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).

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