Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 29 (4) July 2019www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2019 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Editorial: Choices and BarriersContents

page

Barcelona Declaration of the International Society for
Clinical Bioethics: Protection of children’s dignity andrights in the context of new global challenges andincreased vulnerabilities
118
Obtaining informed consent for Cesarean sections in
Bangladesh
119-Mohammad Mahmodur Rahman
A regulatory framework for telemedicine in Indonesia
126- Adi Sulistiyono, Rani Tiyas Budiyanti, Ayun Sriatmi
Youth unemployment in Nigeria: A failed state argument132- Galadima Gladstone Wayas, Sivapalan Selvadurai,
Abd Hair Awang
A review of women’s intellectual contribution under thebureaucracy in Pakistan
138- Salman Ahmed Khatani, Ghazal Khawaja Hummayun
AkhtarInfluence of affluence in the choice of assisted
reproductive technology and why it warrants a policychange142-Sreejith P. S., Krishna G., Chandramohanan Nair K.R.
Living the anthropocene from ‘the end of nature’ toethical prospects
145-Jan Gresil S. Kahambing
Book Review of Beyond Bioethics: Towards A New
Biopolitics
150- Alex Waller
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations (AUSN),
Email: darryl@eubios.info
EJAIB adopts and complies with the Committee on Publication
Ethics (COPE) Publication ethics and malpractice policy. All
potential authors should have read these guidelines and bysubmission of an article for publication you acknowledge thatyou have complied with this policy. Violations will be handled
in proportion to the intention and seriousness of the violation.
Registered address of EJAIB: P.O. Box 16 329, Hornby,
Christchurch 8441, New Zealand- Darryl Macer
Email: darryl@eubios.info
In this issue we start with the Barcelona Declarationof the International Society for Clinical Bioethics:
Protection of children’s dignity and rights in the context
of new global challenges and increased vulnerabilities.
Self-determination is especially a critical issue forvulnerable persons, who often find the barriers to
expression of their will insurmountable. The decision
making capacity of children is often ignored, despite
their autonomy. Khatani and Akhtar illustrate some of
the challenges faced by women in Pakistan in examples
of structured bureaucracy in one of many countries
where government systems do not empower citizens.
The theme of vulnerability and consent is also
explored in other papers in this issue. Mohammad
Mahmodur Rahman explores the process of obtaining
consent in the use of cesarean sections in Bangladesh.
Certain countries have higher level of cesareans, and insome cultures it has become a norm. P. Sreejith et al.,explore the roles of affluence in the choices on assisted
reproductive technology (ART). Affluence also affects
the tendency towards control of timing of birth withcesarean delivery – and we could explore further theway that, ironically, sometimes increased wealth leads
some consumers to expose themselves to technologies
that may actually make them more vulnerable. However,overall access to choices such as ARTs may be a form of
empowerment of people providing options. One of therisk factors for infertility is poverty, which tends to be
associated with higher risks of STDs, as well as poorer
public health and health, increased use of drugs, alcoholand stress.
Jan Kahambing discusses some of the ethicalimplications of the anthropocene, the period of humanactivity on the world in which we live. In the past few
months we can see more examples of biodiversity loss,
which seriously afflict our fellow species on the planet.
There is also a paper exploring telemedicine, which canprovide greater access to medical services for an
increased proportion of the population than before.
Youth unemployment in Nigeria further explores the riseof poverty, and the waste of a generation. Bioethicalsystems of government empower people to provide lessbarriers to their choices, stimulating innovation and life.

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Eubios Journal of Asian and International Bioethics 29 (July 2019)

Barcelona Declaration of theInternational Society for Clinical
Bioethics: Protection of children’s
dignity and rights in the context
of new global challenges andincreased vulnerabilities
XV Annual Conference of the International Society for
Clinical Bioethics, Bioethics and Paediatrics: Future
development and challenges, Barcelona, 20-21
September 2018

Preamble

1. The International Society for Clinical Bioethics
met at her XVth Conference on September 20-21,
2018 in Barcelona and discussed future
developments and challenges in pediatrics, and forchildren’s protection rights, in an effort to make auniversal appeal to ensure every child is protected
for a better future.
2. Children are our common future in our Globe.
They depend on us, on the families, on the states,
and international and local guidelines, andregulations. Children are vulnerable anddependent; therefore, it is our duty to provide themwith a happy future, healthy childhood, andprotection from discrimination and violence.
3. An effort must make to ensure that theinternational, national and local standards toprotect children’s rights are strictly enforced.
Global efforts must be aimed at zero tolerance tothe growing vulnerability of children in the context
of the scientific and technological progress, global
challenges, and migration processes.
4. At the same time, threats to global peace,scientific and technological advances and adeparture from the values of humanism create theconditions and prerequisites for increasing thevulnerability of children, many children still live inthe risk zone.

Problems

5. Threats to the health of children remain
relevant on the international agenda and at thelevel of national states. These include war, poverty,
hunger, racial discrimination, exploitation, adultbrutality and other acts of violence.
6. With increasing migration and displacement,
many children are forced to leave their homes andsometimes their families. There are migrants in all
countries of the world. Their number is growing
faster than the world’s population, and in 2015 itexceeded 244 million people. In fact, every 4.1
seconds there is a new refugee in the world, while
approximately 65 million people are internallydisplaced, including more than 21 million refugees,

3 million asylum-seekers and more than 40 million
internally displaced persons. The UN notes that
46% of the 45.2 million children and adolescents
under the age of 18 are minors who become
hostages of global politics and are even more
vulnerable in these conditions.
7. Scientific and technological progress, designed
to improve the life and health of children, promote
their harmonious development and success, often
creates prerequisites for threats and potential risks,
including the consequences of genetic engineering,
information technology and virtual reality,
cybercrime, the growth of social inequality and lossof access to social benefits, social maladjustment
and many others. It is a reality the 50 % of the
medicines used for children have not been tested
with them, 90 % in the case of premature neonates.
8. We witness the emergence of a disturbing
trend of dehumanization in international andnational legislation in terms of the rights of children
and their parents, and the emergence of legal
norms legitimizing children's euthanasia, which is adirect threat to the life and health of children,
destroys the values of the traditional family.
9. All these problems lay the groundwork fordismantling the values and norms of positive
results that have been achieved thanks to suchbasic international documents as the European
Convention on Human Rights and Fundamental
Freedoms (1953), the Declaration of the Rights of
the Children (1959), Universal Declaration of
Human Rights (1948), and the UN Convention on
the rights of the child (1989).

Tasks

10. Compliance with international guidelines andregulations for the protection of children andadolescents, therefore the United Nations
Convention on the Rights of the Child must berecognized at local, regional, and international
levels.
11. Ensuring children equal opportunities andaccess to healthcare and social benefits. Advancesin science and technology should be aimed to
improve health and quality of life of children,
reducing injuries, disabilities, and causes of childmortality.
12. Protecting children’s rights of migrants, andinternally displaced persons and to preventing
their use for discrimination, exploitation, trafficking,and manipulation, and protecting their personal
space, and cyber-space, and their personal data.
13. Children must be prepared for a responsible
life in a free society and be able to adapt touncertainty, to have the opportunity to define
themselves as individuals, and realize theirpotential in a safe and supportive environment (e.g.,

Eubios Journal of Asian and International Bioethics 29 (July 2019)family, education, sports, etc.) to ensure their wellbeing.
14. Commitment to the values of humanism in
the family, social policies, including those
supported by traditional religions, to strengthen
the relationship between parents, family, andchildren.
15.Bioethical expertise and well-organizedactivity aimed at forecasting new emerging threats
to human potential and vulnerable groups of
population, especially of children, is more and morenecessary.
16. The core of this kind of activity should bebioethical guidelines formulated in terms of clinicaland global bioethics to minimize risks ofvulnerability, to guarantee protection of children's
rights in the context of global challenges andmedical practice.

Ethical duties

We hereby solemnly commit ourselves to:
17. To promote active participation of thescientific and expert community, of which we are apart to protect the well-being of children.
18. To work together within the framework ofinternational cooperation, also on local andregional levels.
19. To include in the agenda of annualinternational meetings topics related to risks ofvulnerability, and protection of the rights ofchildren, and to intensify research in this direction.
Barcelona, September 20-21, 2018
International Society for Clinical Bioethics
Awaya, Tsuyoshi
Japan
Guryleva, Marina
RussiaNakatsuka, Masahiro
Japan
Nezhmetdinova, Farida
RussiaPavlinovic, Silvana
Croatia
Pelcic, Gordana
Croatia
Ribas, Salvador
Spain
Sass, Hans-Martin
United States
Shishido, Keisuke
Japan
Tai, Michael Cheng-tek
TaiwanTomašević, Luka
Croatia
www.linkedin.com/in/iscb

119

Obtaining informed consent for
Cesarean sections in Bangladesh- Mohammad Mahmodur Rahman
Department of Philosophy, Jahangirnagar University,
Savar, Dhaka, Bangladesh
Email: mahmod.philju@gmail.com

Abstract

Primary and secondary level hospitals are yet to
introduce an informed consent procedure before
performing cesarean sections in Bangladesh. Thereis no standard informed consent practice in thetertiary level healthcare institutions and hospitals.
This study argues that the existing informed
consent practice before performing cesarean
section in most of the tertiary level hospitals can be
regarded merely as consent (and I call it mereconsent) rather than informed consent. The private
hospitals and clinics usually provide so-called
informed consent forms. Majority of these hospitals
and clinics consider the informed consent as an
institutional procedure rather than ethicalprocedure; and they use the informed consent form
as a safeguard if there is any trouble concerning thesafety of patient. This study concludes that
informed consent in true sense needs to bepracticed in cesarean sections. Obtaining informed
consent may provide moral confidence to thephysicians and inspire them to become ethicalphysicians. At the same time, it will create suchawareness among them so that they realize a major
surgery like cesarean section cannot be performed
without the proper informed consent of the mother.

Introduction
Informed consent is one of the basic rights ofpatients which physician should honor for thewelfare of the patients. In order to participate in thedecision-making process of the treatment, a patient
can rightfully ask questions related to treatment
from the concerned physician. The philosophicalbasis of informed consent derives from theprinciple of respect for autonomy which strongly
demands patient’s involvement in the decisionmaking process of the treatment. However,informed consent is more of a legal and ethicalprocedure rather than a signature on a form. This
paper focuses on the necessity and importance ofobtaining informed consent concerning cesarean
sections in Bangladesh. It argues that some of thestandard hospitals in the country do not follow theproper procedure of informed consent; what they
do can rather be called “mere-consent”. This paper
suggests that an informed consent in real sense120

Eubios Journal of Asian and International Bioethics 29 (July 2019)needs to be implemented for cesarean section at
hospitals; and physicians should obtain informed
consent before performing cesarean sections.
Mere-consent and informed consent
Giving a mere-consent is a way of allowing anaction to be performed. If anyone agrees to allow
something, that constitutes a consent. It seems thatsaying “ok” or showing particular affirmation in acertain case can be considered as giving a mereconsent. One may give a mere-consent orally or one
may give a mere-consent in written. Mere-consent
may involve seeking the permission to perform any
task but may not always include rational decisionmaking process. Hence, just obtaining a mereconsent (not really informed consent) may not beenough for performing any cesarean section.
In contrast, an informed consent invokes rational
decision-making process and demands a friendly
and an effective relationship between two agents. It
includes alternative options and a decision from theparticipants also. Here both agents discuss the
problem to get the best solution and are informed
about all the pros and cons of the issue. The
solution may come from any participant. In short,
informed consent must include a rational decisionmaking process and all information should be
disclosed before coming to a final decision. On theother hand, in case of a mere-consent one
participant, in fact the patient is only eligible to say“yes” or “no”. She may not be allowed to saysomething more than “yes” or “no” and even may
not offer any alternative option. Most of the time
the other participant, in fact the physician plays thevital role in decision making.
Obtaining an informed consent is a legal
procedure which is required for ethically soundmedical practice. Physicians need to disclose eachand every bit of the relevant information including
risks and benefits, side effects, costs of the
proposed treatment, available alternative optionsof the treatment and so forth. Therefore, obtaining
a mere-consent is merely seeking permission
whereas obtaining an informed consent is seeking
permission for a treatment to be performed after
explaining the positive and negative sides of thetreatment. However, patients have the right toagree or disagree with the proposed treatment. Oneof the main requirements for obtaining an informed
consent is that patients need to be competent tounderstand the disclosed information so that they
can take decisions voluntarily which are free fromany coercion or influence. A written informed
consent is preferable to verbal consent.
The practice of obtaining mere-consent insteadof informed consent is a medically questionable
practice because it only cares about patients’autonomy whereas the other three principles ofbiomedical ethics are ignored. On the other hand,obtaining informed consent not only includes
patient’s autonomy but also cares about the welfareof the patients. Such obtaining of informed consent
fulfills all the four basic principles of biomedical
ethics1. But the medical practice in Bangladesh,
especially for cesarean sections is questionable as it
opens the door for obtaining mere-consent basedon medical practice.
Necessity of obtaining informed consent on
the basis of four principles
The philosophical foundation of informed consent
rests on the principle of respect for autonomy.
Respect
forautonomy
demands
healthprofessionals to build a sound relationship withpatients so that patients can make their own
decisions. “Autonomy” and “respect for autonomy”
are used closely in medical practice. Kant
emphasized on the autonomy concept. According to
Kantian ethics, one cannot act morally unless the
person is autonomous (Wood 2008, 106). These
terms are thought to be consistent with informed
consent procedure and are closely related with theelements of informed consent such as privacy,
voluntariness, choosing freely and the freedom tochoose and taking responsibility for that action.
Beauchamp and Childress write, “We think that
respect for autonomy does provide the primary
justification of rules, policies, and practices of
informed consent (Beauchamp and Childress 2013,121).” Faden and Beauchamp (1986, 235) claimthat an analysis of the nature of autonomy provides
the essential foundation for their analysis of thenature of informed consent. So, we can say that
informed consent is very much needed from thesense of autonomy especially from the principle ofrespect for autonomy.
The main purpose of the principle of beneficenceis doing good to the patient in any medical practice.
Informed consent suggests physician to establish aneffective relation with patients for their welfare. A
treatment cannot be ethically sound if benefits ofthe treatment do not overcome the risks of it.
Moreover, an important element of informed
consent is to share the possible risks/benefits ofthe treatment to the patient. When a physician is
altruistic to his patient, he or she does not hesitate
to help the patient make decisions regarding
treatment. The principle of beneficence suggests
the physician to be altruistic to his patients. In
1 In biomedical ethics, the four principles are respect forautonomy, beneficence, nonmaleficence and justice.
These principles are introduced by Beauchamp andChildress who are thought to be the pioneer ofbiomedical ethics. These principles are widely acceptedby ethicists.

Eubios Journal of Asian and International Bioethics 29 (July 2019)
addition, informed consent is in legitimate interestof a patient. Thus, informed consent can be called a
legal right of a patient. Some physicians are notaware of this legal right. Physicians begin theirstudy in medicine by Hippocratic Oath.2 Although
they learn about certain laws, they may not careenough about this legal right. This right is notemphasized as a duty as mentioned in Kantian
ethics. If physicians take this as their duty, theycannot deny it. The principle of beneficence obliges
a physician to fulfill patient’s legitimate interest.
Beneficence also suggests a physician to be kind to
his patient. When physicians show kindness to theirpatient, they become able to realize the patient’s
interest. Eventually physicians become aware to do
the right thing to the patient. So, physicians need tocare about patient’s decision. They need to try theirbest to make every kind of help to a patient formaking a proper decision about treatment. When apatient is in trouble to make a treatment decision,
physician is the most reliable person to assist thepatient.
The first and foremost demand for principle ofnonmaleficence is doing no harm to patients bymedical practice. Although informed consent is an
ethical doctrine, we have seen that sometimes it canalso be called as a legal right of a patient. So, if
physicians do not obtain informed consent before
any medical treatment, it is like ignoring a patient’s
legal right. The informed consent procedure
demands the exposure of each and every effective
information of possible treatments. If physicians do
not provide so, then patients become ignorant of
their treatment procedure. In that situation, they
are unable to make the proper decision. So, hiding
information regarding the treatment proceduresometimes may be harmful to the patient.
Therefore, depriving patients from the proper
information is not permissible according to theprinciple of nonmaleficence. In addition, informed
consent may ensure the welfare of a patient. So,
physicians cannot ignore obtaining informed
consent; rather it is their responsibility to obtain
informed consent before any medical practice.
Informed consent is also necessary from theperspective of principle of justice. The generaldemand of justice is fairness. One of the main
purposes of obtaining informed consent is also toestablish fairness in medical practice. Physiciansneed to be honest regarding the treatment
procedure, risk-benefit analysis, and alternative
options for the treatment procedure and so forth.
2 The Hippocratic Oath explains the obligations of thephysician to medical students. This oath suggests
physicians to consider the welfare of patient and refrainfrom doing harm. It encourages them to lead an imitable
life.

121

One of the important elements of informed consent
for a competent patient is the absence of coercion.
Justice can ensure this condition. “Right based
justice” is derived from the principle of respect forautonomy which emphasizes on proper respect toindividual’s right. Every patient has the right to be
informed about his or her treatment. In this regard,
informed consent can be called an individual rightof a patient who deserves proper respect from aphysician before any medical practice. Besides,“legal justice” approves various types of morally
accepted laws and informed consent is one of them.
Informed consent needs to be obtained
regardless of patients’ position, gender, and wealth.
According to Daniels (1985) “fair equality ofopportunity” requires that no person irrespectiveof natural disadvantages (e.g. malnutrition) andsocial disadvantages (e.g. tribal community) should
be deprived of any benefit because of a socialy
disadvantageous situation. Daniels follows Rawls’
theory of justice in the healthcare system withspecial focus on “fair equality of opportunity”, andargues that healthcare needs are special as they
ensure proper functioning and opportunities of aperson. So, if a patient comes from a poor family,
he/she deserves an equal care with a patient from arich family. “Fair equality of opportunity” focuseson maintaining moral and legal rights of thepatients regardless. As informed consent has both
legal and ethical implications, it needs to beobtained from each and every patient.
We can say that a woman must have the right totake decision whether she will choose cesarean ornot. Thus, performing surgeries like cesarean
section needs to be approved by the patients with aprior informed consent, otherwise it may not bejustified.
The present scenario of Cesarean section in
Bangladesh
Cesarean sections are the most widely performed
surgery for women in Bangladesh. Normally acesarean delivery should be performed when it is
not possible to deliver a baby through normal orvaginal delivery because of various complications
which may endanger the life of mother or baby. The
rate of cesarean section in Bangladesh has been
increasing. The percentage of the Cesarean sectionin the country was 31.3% in 2014. The rate ofcesarean section increased to 37.9% within a year
in 2015 which is far away from the World HealthOrganization recommendation range of 10 to 15
percent (Management Information System 2016,54). Overall, different reports show different rates
of increase of Cesarean sections in Bangladesh.
However, all of them agree with the increasing
number of Cesarean sections.

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Eubios Journal of Asian and International Bioethics 29 (July 2019)

The above-mentioned phenomenon occurs dueto the fact that most of the time physicians are
reluctant to wait for normal deliveries and suggest
surgical ones. They do not even wait for obtaining
informed consent which is required before
performing a Cesarean section. The following
scenario make this situation clear:
Governmental healthcare institutions
Based on facilities provided, healthcare institutions
in Bangladesh can be divided into three major
categories: primary, secondary and tertiary. Most of
the public primary healthcare institutions are
situated in ward, union and sub-district (upazilla)
level which is called Upazilla Health Complex (UHC).
At present the number of Upazilla Health Complex
hospitals in the country is 411; 132 of them provide
comprehensive emergency obstetric care where
cesarean section is performed and the rest provide
basic obstetric care (MIS 2016, 53). Secondary
healthcare institutions are mostly government
district
hospitals
andgeneralhospitals.
Government medical college hospitals, specialized
hospitals and post-graduation health institutions in
the country, Bangabandhu Sheikh Mujib Medical
University (BSMMU), are the tertiary level healthinstitutions.
According to Health Bulletin 2016, a total of
175,888 cesarean deliveries were performed in2015 at governmental healthcare hospitals. Table 1
illustrates the country’s obstetric care services (MIS
2016, 55).

and divisional cities. Hospitals situated in thoseareas provide the highest level of public obstetriccare services in the country. Some of the hospitals
at that level consider informed consent
insignificantly while most of them do not even care.
Figure 1 shows a sample of so called ‘informed
consent’ practice from one of the advanced tertiarycare hospitals in Bangladesh. Most of the time
hospital authorities provide this sort of form when
the patient gets admitted into the hospitals.
Firstly, we notice that the permission was takenfrom the guardian (name: Moni) who is thehusband of the patient and the permission was nottaken from the patient herself without any
indication of special or emergency situation. Taking
consent from a patient’s guardian is not justified
because it requires patient’s participation in thedecision process. But it is a common scenario thatpatient’s involvement is ignored in the decisionmaking process. Secondly, we cannot accept theprocedure as an informed consent. It is a mereconsent. This procedure only seeks the permission
to perform Cesarean but does not include rational
decision-making process. Disclosing the riskbenefit of the treatment is a vital part of informed
consent procedure which is clearly absent in thisform. Moreover, this form only presents
institutional obligation but no ethical obligation.
Therefore, it can be said that hospitals or
authorities use this sort of form as a safeguard
when any trouble occurs.

Table 1: The numbers of governmental and nongovernmental emergency obstetric care facilities in
Bangladesh, 2015
N%
Postgraduate medical institution
3,403
1.9
hospital
Medical college hospital
53,137 30.2
District hospital/ general hospital
41,751 23.7
Upazilla health complex
19,561 11.1
Other govt. facilities at Upazilla
58,036
33
level
Total
175,888

I agree that my patient undergo cesarean operation
under general or local anesthesia. If the patient orbaby suffers any problem because of the operation,
the hospital or authority will not be responsible.

A report published by the Directorate General of
Health Services, shows that 44.1 percent ofcesarean deliveries were performed in upazilla
based government hospitals in 2015 (MIS 2016, 54).
But there is no evidence that physicians at thatlevel obtained informed consent before performing
cesarean sections. Normally district hospitals andgeneral hospitals provide better obstetric care thanupazilla health complexes. But it is a matter ofregret that informed consent is ignored there too.
Most of the public tertiary care hospitals which
provide obstetric care are situated in the capital

Only one institution, Bangabandhu Sheikh Mujib
Medical University (BSMMU) provides a muchbetter and relatively clear informed consent form,
but the actual practice of informed consent remains
uncertain and even if so only 1.9 percent of all
Cesarean sections in government facilities are
performed there. On the other hand, almost 60
percent of Cesarean sections are performed inother tertiary hospitals in Bangladesh.

Moni

Figure 1: Sample of so called ‘informed consent’practice in a tertiary level hospital in Dhaka, withEnglish translation

Eubios Journal of Asian and International Bioethics 29 (July 2019)Non-governmental hospitals and healthcare
institutions
Private hospitals, clinics and NGO driven healthcare
institutions provide obstetric care for women.
According to Health Bulletin 2016, a total of
306,725 cesarean deliveries were performed in
non-government hospitals in 2015 compared to223,514 in 2014. Among them 93.1 percent were
performed in private hospitals and clinics. The rest
were performed in NGO governed healthcare
institutions (MIS 2016, 55). But surprisingly the
number of cesarean deliveries in the private
institutions and hospitals has increased to 750,000
in 2016 (National Institute of Population Research
and Training et al. 2016, 57). The practice of
informed consent before performing Cesarean inprivate hospitals of Bangladesh is vulnerable andfrightening.
A case study was recently published in one of themost popular newspapers of Bangladesh. A patientname Shazneen Begum, a public health specialist byprofession, was taken to a well-known private
hospital in the capital city as her water broke in the
38th week. She was told that meconium got mixed
with the amniotic fluid and the baby was floating
inside her womb. As her earlier delivery was
normal, she wanted to wait for a normal delivery at
this time too. But the doctor refused to take any
responsibility for any negative outcome andjustified that she go under the surgery. Shazneen
Begum, on an interview mentioned that thecommunication process of the doctor was notsupportive but threatening. She also added that
there was a lack of sufficient information regarding
her condition. She stated, “I was just told that it wasgoing to be complicated. I was never explained therisks associated with stool (meconium) mixed in
the amniotic fluid properly” (Karim 2017, 4). This
study clearly indicates that informed consent was
not obtained as informed consent procedure cannot
be completed without explaining proper risk andbenefit of performing Cesarean section. Although
the patient wanted to know the details, she wasrefused. This type of scenario is very familiar in the
Cesarean sections in the private sector in
Bangladesh. It is quite rare to wait and try for anormal delivery in private clinics or hospitals in
Bangladesh.
Like government hospitals, private clinics andhospitals provide the so-called informed consent
form. But most of the times this is not given to thepatient. Before the anesthesia, hospital authority
takes a signature from patient’s representative or
legal guardian. They informe the guardian that if
any complicacy arises to the patient or baby, they
will not take any responsibility for that. The
authority takes the sign from the guardian only as
their safeguard. Most of the Cesarean deliveries

123

recommended by physicians in private hospitals in
Bangladesh are questionable. A very recent reportfinds that 70 percent of the cesarean deliveries in
Bangladesh are unnecessarily performed (“70% of
Caesarean births”).
Village doctors and midwifery
Approximately 65% of people in Bangladesh live inrural areas (World Bank 2017). The majority ofwomen living in village rely for their emergency
obstetric care on village doctors and untrained
midwives. There are several types of clinics in rural
areas. Sometimes a rented house having few rooms
with limited instruments forms a clinic. Womenfrom poor families are their main clients. Untrained
doctors are also performing Cesarean sections
there. They do not care about informed consent.
Some do not even know what informed consent is.
Poor ethical standard of Cesarean section in
Bangladesh
A recent report suggests that 70 percent of the
Cesarean section in Bangladesh is “unnecessary”
which cost the patient US $315 million annually or
US$552 per operation (Mannan 2017). Thismammoth amount not only demonstrates theunethical business of hospitals but also indicatesthat the ethical standard of the hospitals is not up
to the mark. Institutions like hospitals should not
act like other financial institutions which focus onmoney making. Besides, patients being used asmeans for the individual welfare of the physician
cannot be acceptable from a Kantian standpoint.
This practice is completely immoral. Sometimes
physicians provide incomplete information to themothers and their families. This also indicates thatphysicians are unaware about their duties andreluctant to go by ethics and morality. Most of thetime they do not feel the obligation by the principleof “do no harm”, while it is an obligation to do no
intentional harm to others. In medical ethics, itobliges physician to refrain from doing any harm topatients. According to many ethicists, it is thefoundation of ethics in medical treatment.
According to a study the average length ofprimary care physician consultation time was 48
second per person in 1994, which has increased to
2 minutes per patient in 2015 in Bangladesh (Irving
et al. 2017, 5). This length was the longest in
Sweden at 22.5 minutes. This duration is 21.07
minutes in USA, 15 minutes in Australia and Canada,
and 3.4 minutes in Pakistan. Even the consultation
time is higher in our neighboring country India.
Consulting a patient for 2 minutes can never besatisfactory. Even when a physician from a public
hospital visits a pregnant woman in private clinics
or hospitals normally he spends significantly moretime than for a pregnant woman in public hospitals.

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Eubios Journal of Asian and International Bioethics 29 (July 2019)

It is not unfamiliar that the same physician, who
gives his or her patients only a minute or two in
public hospitals, gives 10 to 12 minutes in private
hospitals.
Private hospitals and clinics of Bangladesh areoperated under Medical Practice and Private Clinics
and Laboratories (Regulation) Ordinance, 1982. The
ordinance does not include obtaining informed
consent as a mandatory procedure before medical
intervention. So, physicians in private hospitals opt
for Cesarean sections which are in some cases notnecessary. Besides, Bangladesh Medical and Dental
Council (BMDC) which is one of the apex regulatory
bodies under the Ministry of Health and Family
Welfare suggests obtaining informed consent inscientifically assisted reproduction and related
technologies like artificial insemination. We can saythat this guideline is for special cases only andthere is no general guideline for obtaining informed
consent before general medical practice in the
country. However, MBBS students learn about“medical jurisprudence” as well as health ethics inthe forensic medicine course. The curriculum offers
emphasis only on obtaining consent while informed
consent is ignored (Bangladesh Medical and Dental
Council 2012). Therefore, the absence of informed
consent in policy and curriculum level has anegative impact on the thical aspect of medical
practice like performing cesarean sections.
Implementation of informed consent in true
sense in Cesarean section in Bangladesh
After the above discussion, we find that, there is no
standard practice of informed consent all over thecountry; there are no clear rules and regulations
from the governmental authority to obtain
informed consent before performing Cesarean
section as well. Basically, Cesarean section is a lifesaving surgery. Performing any surgery without
informed consent is not ethically acceptable.
The main purpose of a cesarean delivery is thewelfare of mother and baby. 83 percent of the total
performed Cesarean deliveries in private
healthcare institutions has not been proved to be
helpful for the significant reduction of maternalmortality ratio (MMR) or child mortality rate of
Bangladesh. 46 percent of all performed cesareandeliveries in public healthcare institutions has notproved to be helpful in this respect either.
According to Bangladesh Maternal Mortality and
Health Care Survey 2016, MMR has increased to
196 maternal deaths per 100,000 child births in2016 which was 194 in 2010 (NIPORT et al. 2016,93). Thus, these Cesarean practices cannot bejustified on the ground of MMR reduction. As mostof these deliveries are performed without proper
informed consent; hospitals and authorities do nottake any responsibility for the harmful incident.

If physicians obtain informed consent before
surgery, they would be liable for any harmful
incident and that would make them performsurgery with utmost care. This type of cautious
practice (not to harm patient) will give physicians
moral confidence and will give positive impetus tobecome an ethical physician. If physicians obtain
informed consent, it will also help them to become
an ethical person too. After all, if physicians takeresponsibility to maintain proper informed consent
procedure, the scenario will be different. There aresome cases when women choose to go under
Cesarean section without proper reason. If they areproperly informed about the risk-benefit of thesurgery and alternative options, they may choose anormal delivery.
In our everyday life we have to sign various typesof contract. We need to sign before buying land,house, and apartment or even before getting
married. Most of these cases we are clearly
informed about each and every detail of thosecontracts. Similarly, in case of a surgical operation
like Cesarean section, the practice of informed
consent needs to be transparent like those so thatpatients will know every detail of the proposed
treatment. Moreover, informed consent is an ethicalprocedure rather than a form. Being informed
should be given priority.
Bangladesh is an over populated country having
a lot of illiterate people. Therefore, expecting
miraculous change in the near future will be a
dream. Nevertheless, the prevailing situations in
Cesarean section should not continue. Obtaining
informed consent can change the existing situation.
It can decrease unnecessary Cesarean operation as
well as unnecessary financial expenses. If informed
consent is properly obtained, then it is possible that
only those women who really need Cesareandelivery and have no other option will go under thissurgery. As a result, the rate of Cesarean delivery
will decrease to a moderate level. As an effect, thecost for unnecessary Cesarean operation will bedecreased. Therefore, it can be strongly claimed
that informed consent practice is seriously neededin the Cesarean section of Bangladesh to maintainthe welfare of mother and baby as well as to reduce
the unnecessary physical and monetary sufferingsof persons undergoing it.

Conclusion

The present scenario of Cesarean sections in
Bangladesh is not in favor of welfare of concerned
citizens. The vast amount of Cesarean deliveries isbeing performed without maintaining proper
ethical norms and regulations, especially in theabsence of informed consent requirement. The
activities that are performed for Cesarean section in
Bangladesh deprive patients from making proper

Eubios Journal of Asian and International Bioethics 29 (July 2019)
medical decision and sometimes risk their lives.
Lack of proper procedure of obtaining informed
consent leads to unethical practices which cannot
be supported from the Kantian viewpoint.
Physicians in public hospitals need to be ethicallyaware and should give more consultation time tothe patient. They need to wait for patient’s decision
as long as possible. In this article I have attempted
to clarify that the practice of standard informed
consent instead of mere-consent is an urgent needto solve many ongoing unethical activities in the
Cesarean sections. I have also explained that,
informed consent must be practiced considering it
as the doctrine of ethical obligation, not just as an
institutional formality. Obtaining informed consent
from mother before performing Cesarean delivery
will help physicians to give proper allegiance to
Hippocratic Oath. Their aim will be welfare of thepatients.
Acknowledgements
I would like to express my gratitude to Professor Dr.
Md. Munir Hossain Talukder at Jahangirnagar
University, Bangladesh for his generous guidance
and meticulous efforts in regard to going throughseveral drafts of my research paper.

125-births-boom-endangering-womens-livesbangladesh/.
National Institute of Population Research and Training(NIPORT), International Center for Diarrhoeal Disease
Research, Bangladesh (icddr,b) and Measure
Evaluation. (2016). Bangladesh Maternal Mortality
and Health Care Survey 2016. Dhaka, Bangladesh:
NIPORT, icddr,b and measure Evaluation, 2016.
https://www.measureevaluation.org/resources/publi
cations/tr-17-218.
The Medical Practice and Private Clinics andLaboratories (Regulation) Ordinance, 1982. 2017. 27
May,
1982.
http://bdlaws.minlaw.gov.bd/print_sections_all.php?id=620, accessed: 25 November, 2017.
The World Bank. Rural Population (% of total
population).
https://data.worldbank.org/indicator/SP.RUR.TOTL.Z
S?locations=BD, accessed 2 September, 2017.
Wood, Allen W. (2007). Kantian Ethics. Cambridge:
Cambridge University Press.
The Financial Express. 70pc of Caesarean Births in
Bangladesh ‘unnecessary’. 15 August, 2017,
http://epaper.thefinancialexpress.com.bd/?archiev=yes&arch_date=15-08-2017.

Appendix 1: Informed consent form of obstetrics andgynecology department, BSMMU

References

Bangladesh Medical and Dental Council. (2017). Forensic
Medicine in MBBS Curriculum Update. Available at:https://docs.google.com/viewer?url=http://bmdc.org.bd/wp-content/bmdc/c2012/5Forensic%20Medicine.pdf, accessed: 23 November,
2017.
Beauchamp, Tom L., and James F. Childress. (2013).
Principles of Biomedical Ethics. 7th ed. New York:
Oxford University Press.
Daniels, Norman. (1985). Just Health Care. New York:
Cambridge University Press.
Faden, Ruth R., and Tom L. Beauchamp. (1986). A History
and Theory of Informed Consent. New York: Oxford
University Press.
Irving, Greg, Ana L. Neves, Hajira Dambha-Miller, Ai Oishi,
Hiroko Tagashira, Anistasiya Verho and John Holden.
(2017). International Variations in Primary Care
Physician Consultation Time: a Systematic Review of
67 Countries. BMJ Open 7 (10): 1-15.
Karim, Naimul. 2017. The Curious Case of the C-section.
The
Daily
Star,
Star
Weekend,4-5.
http://www.thedailystar.net/starweekend/health/the-curious-case-the-c-selection1432768, accessed: 15 July, 2017.
Management Information System. (2016). Health Bulletin
2016. Dhaka: MIS, Directorate General of HealthServices, 2016. http://www.dghs.gov.bd/index.php/en/home/4364-health-bulletin-2016.
Mannan, Ishtiaq. 2017. Caesarean Births ‘boom’ isEndangering Women’s Lives in Bangladesh. AsianCorrespondent,
15
August2017,https://asiancorrespondent.com/2017/08/caesarean

Translation: Consent paper for operation:“I, myself/my patient is informed about all the necessityand possible risks of the operation by Doctor…... Afterthat I/my patient voluntarily and consciously approvesof performing partial/full anesthesia for the operation. I
consent to the on-duty surgeon to take every possible
arrangement for the sake of patient’s welfare in case ofany emergency. Hospital authority or surgeon will not be
responsible for any accident during operation/
anesthesia.”

126

Eubios Journal of Asian and International Bioethics 29 (July 2019)

Appendix 2: Informed consent form of a tertiary levelgovernment hospital in Bangladesh

medical device standards, data privacy andconfidentiality,
data
protection,
distance
contracting and electronic signature, license andcertification of healthcare and health professional,
juridiction law, legal liability, and also e-prescribing.
Indonesia needs specific regulations oftelemedicine, so that the implementation oftelemedicine will not be not contrary with ethics
and other regulations.

Introduction

Translation of the consent part“I, on behalf of my patient agree to undergo cesarean
operation by performing anesthesia. If patient or baby
suffers any problem because of operation, hospital or
authority will not be responsible for that.”

A regulatory framework fortelemedicine in Indonesia- Adi Sulistiyono
Faculty of Law, Universitas Sebelas Maret, Indonesia- Rani Tiyas Budiyanti, Ayun Sriatmi
Health Policy and Administration, Public Health Faculty,
Diponegoro University, Indonesia
Email: ranitiyasbudiyanti@gmail.com

Abstract

Telemedicine is the use of telecommunications toprovide information and medical services from a
distance. There are legal issues related to
implementation of telemedicine such as privacy
and confidentiality of patient information, licenseand certification of provider, and legal liability. This
technology has developed in Indonesia. However,Indonesia does not have specific regulations about
it. This study aims to find out the legal aspects oftelemedicine that are appropriate to be applied inIndonesia.
This research is normative research with statue
approach and conceptual approach. The researchmaterial was obtained through literature review
from legislation, court decisions, books, journals,
and proceedings, both national and international.
The legal aspects of telemedicine in Indonesia
consist of the legal definition of telemedicine,electronic medical records/electronic health record,

The development of information technology hasreached all aspects of life, including the healthservices area. The emerging technology in healtharea is telemedicine technology. Telemedicine is
the use of technology to provide information andremotehealthservicesthat
includeteleconsultation, tele-expertise, teleassistance,
telemonitoring, and medical emergency call center.
(Bilo et al, 2014)
Telemedicine is inside the health focus inIndonesia. It is the focus of Strategic Plan (Renstra)of the Ministry of Health 2015-2019. With thistechnology, communication between patients,
doctors, and health facilities can occur remotely.
Implementation of telemedicine in Indonesia will
provide some benefits. It’s appropriate withIndonesia’s geographic condition that consists ofmany islands. In addition, there is a maldistributionof healthworkers in Indonesia. Most doctors are
centered in big cities (Anisa & Menaldi, 2015). With
telemedicine technology, health services andinformation can be provided without limitations of
distance and time. It can improve the quality ofhealth in Indonesia and can decrease the number ofreferrals. It also can decrease self-diagnosis and self
medication.
The impelemtation of telemedicine in Indonesia
has several challenges including the guarantee of
patient rights, the potential for the release of
information and patient data, licensing issues andcertification of service providers, and legal liability(Isabelle, 2010). The problem is very crucial,because in the health service, the patients’ rights
must be fulfilled. But, until now, there is no
regulation for implementation of telemedicine inIndonesia.
Malaysia has had specific regulations ontelemedicine called the Telemedicine Act 1997
(Laws of Malaysia, 1997). India also has a special
regulation of the Telemedicine Act 2003 (Mable,2010). Meanwhile, Indonesia has no specificregulation on telemedicine yet. Therefore, thisstudy aims to examine the legal aspects oftelemedicine
inIndonesia,
so
that
its
implementation is not contraty to the patient’s
rights, ethics, morals, and other regulations inIndonesia.

Eubios Journal of Asian and International Bioethics 29 (July 2019)
Research Methods
This research is a normative research using a
conceptual approach. The research material
consists of primary legal materials (legislation
relating to telemedicine in Indonesia), secondary
legal materials (legal journals, law books, and legal
proceedings), as well as non-legal materials(journals, books, and proceedings on telemedicine).

Eprescribing

Legalliability

Yuridiction
law

Legal
definition
EMR/EHR

Legal
concept ofTelemedicine

License andcertificationofDistance
healthcare contracting
and healthandprofessional electronic
signature

Medical
Devicestandard
Data
privacy andconfidential
ity

Data
protection

Figure 1: Legal concepts of telemedicine in Indonesia

Findings and discussion

Regulations in the implementation of telemedicine
are needed to ensure the patient rights. The legal
aspect of telemedicine in Indonesia includes thedefinition of telemedicine, electronic medical
records, standard medical devices used intelemedicine, privacy and confidentiality data, dataprotection, remote contracts and electronic
signatures,
jurisdictional
issues,legal
responsibilities, and online prescribing.
Legal definition of telemedicine
The definition of telemedicine is a crucial matter tobe agreed, because in the legal context, definitions
determine whether a service is included in thecontext of telemedicine or not. According to the
Minister of Health of the Republic of Indonesia
Decree Number HK.02.02 2016 on Trial Hospital ofVideo-conferenceandTeleradiology-based
Telemedicine Service Program, telemedicine is ahealth service that can be provided remotely
through the use of communication and information
technology for guidance/diagnostic consultationand management of patient care between thehealth care facilities of the facilitators and those
who are taught. However, the regulation does not
mention further the scope of telemedicine.
Telemedicine services can be done on real timebasis (synchronized) such as videocall or audiocall
and not realtime (asynchronized) such as chatting
or sending emails. According to Blio et al,
telemedicine consists of teleconsultation, teleexpertise, telemonitoring, tele-assistance, andmedical emergency calls (Bilo et al, 2014)127

Teleconsultation is consultation between
patients with remote health workers. It’s
appropriate for use in Indonesia. In 18 provinces inIndonesia (55% of the total provinces), more than
94.1% of families are located more than 5kilometers from health facilities (World HealthOrganization, 2013). Currently there are many
teleconsultation services developed in Indonesia,
both in the form of standalone applications andweb-based. Some health services also can open
remote consulting services to their patients. In
teleconsultation, patients communicate with
doctors or other health professionals to findsolutions for the health problem. At present,
teleconsultation is in great demand by patients
because it is more efficient in terms of time, cost,and energy. In addition, patients can get second
opinions from other health workers easily without
limitation of distance and time (Gersal et al, 1999).
Tele-expertise is a remote consultation between
one health worker and another healthworker who
is more skilled. This technology can bridge thespread of health workers such as uneven doctors or
specialists (Doumbouya, 2015). In some cases,
health workers can consult with other experts sothat they can reduce referral rates. Indonesia hasdeveloped long-distance consultations on radiology
called teleradiology. This technology is used
between hospitals in Indonesia.
Telemonitoring is remote monitoring of thepatient’s health conditions such as monitoring vital
signs. In this monitoring, an alarm or emergency
sign can appear if there are problems with thepatient so that actions can be done immediately(Bilo et al, 2014). The development oftelemonitoring in Indonesia has not been a focus.
Another scope of telemedicine is teleassistance.
Teleassistance is the use of remote assistants inhealth service (Bilo et al, 2014). Telemedicine inthis form is often used in surgical procedures(telesurgery /teleintervention). In a telesurgery
procedure, the surgeon can be in another healthfacility, while an assistant who can be a robotic
surgery assistant is in the area that is directly
dealing with the patient. The surgeon can move therobotic arms remotely to perform the surgicalprocess on the patient (Andrew et al, 2018). In
Indonesia, telesurgery has been applied by one
hospital in Jakarta since 2010 (Hospital of Bunda,
2018). Nevertheless, telesurgery has not been oneof the focuses of telemedicine development inIndonesia.
Medical emergency call is a form of telemedicine
in the form of a marker for long-distanceemergency conditions. Patients with a history of
hypertension for example will have a higher risk ofstroke and heart attack. By knowing the level of riskthat may occur, patients can prepare themselves for128

Eubios Journal of Asian and International Bioethics 29 (July 2019)

emergency calls in the event of an emergency thatthreatens life, both to people around, family, andnear health facilities. With this technology, it isexpected that assistance services can be provided
immediately to increase the patients’ life
expectancy (Bilo et al, 2014).
Apart from its scope, telemedicine is often
defined based on the type of clinical services
performed such as teleradiology (for long distanceradiology services), telecardiology (remote cardiac
services), telesurgery (remote surgery), and so on.
Both consultation between patients and doctors,
and consultation between health workers,
monitoring, and assistance may be called
telemedicine.
Electronic medical records (EMR)
In the implementation of telemedicine, the role ofmedical records is important. Article 46 paragraph(1) of Law Number 29, 2004 on Medical Practices
states that every doctor or dentist in carrying out
medical practice is obliged to make a medical
record. According to Article 1 number 1 of theRegulation of the Ministry of Health in Indonesia
Number 269, 2008 on Medical Records, medical
records are files containing records and documents
including patient identity, examination results,
treatment given, and other actions and services thathave been given to patient.
Medical records were conventionally stored as
paper-based. However, along with the developmentof
information
technology
includingthedevelopment of telemedicine, electronic-based
medical records (EMR) began to emerge. EMR is anelectronic record or recording of a person’s healthinformation. The information is created, stored, andmanaged in the form of electronic data by doctors
and health workers who have the right in a healthservice organization (Badeia, 2016). There areseveral advantages in using EMR including the easeof clinical decision making (decision support
system) such as the patient’s medical action plan,care, and treatment. Another advantage is the easeof monitoring patient data, and research datacollection. Even so, the implementation of EMR has
severalchallenges
suchas
substantial
infrastructure costs, data and network security,
data confidentiality, and inexperienced resources(Bdeia, 2016).
Until now, there has been no specific regulationin Indonesia to regulate electronic medical records.
However, in the implementation of telemedicine,electronic medical records are very crucial. Data on
the results of long-distance health services in theform of text, images, videos, or sounds are forms ofelectronic medical records that must be kept inprivacy and confidentiality. Therefore, special
regulations are needed regarding electronic

medical records to support the implementation oftelemedicine in order not to conflict with the ethics,
morals, and laws in Indonesia.
Medical device standards
The use of medical devices must be considered intelemedicine. In the consultation process in thecase of dermatology, for example, standardizationof data is needed to take or transmit images likeskin disorders (Tensem, 2016). Differences in data
sent and received due to compression may
influence the diagnosis and therapy.
In telesurgery that uses tele-assistance withrobotic surgery assistance, standard tools are very
important (Andrew et al, 2018). Standardization of
medical devices can be done with HealthTechnology Assessment (HTA). In Indonesia theimplementation of HTA is carried out by the
Appraisal Committee for Health Personnel who
carry out comprehensive health technology studies
including efficacy, effectiveness, safety, economic
analysis, budget impact analysis, as well as social,
cultural and religious values (Ministry of Health inIndonesia, 2017). However, Indonesia does nothave a specific regulation regarding HTA,
telemedicine technology, including regulations
regarding standard devices used in telemedicine.
Devicestandards
affectsecurityandeffectiveness that will affect the legal, ethical, andeconomic factors of the patient. With thestandardization, the calibration can be done
periodically in accordance with the standards. Thiscan reduce the risk of errors in medical devices thatcause harm to patients. This standardization is alsoneeded to distinguish malpractice events or error
in medical devices.
Data privacy and confidentiality
Protection of data and privacy of patient data needs
to be considered in the implementation oftelemedicine. This is because the protection of thepatient’s medical secrets is the patient’s right.
According to Article 2 paragraph (1) Regulation of
the Minister of Communication and Information
Number 20, 2016 on Protection of Personal Data inElectronic Systems, includes protection against
acquisition, collection, processing, analyzing,storing,
displaying,
announcing,sending,
disseminating and destruction of personal data.
In the implementation of telemedicine, thepractice of sharing patient data between one healthcare facility and another is common (Michael,2010). Although it can provide convenience topatients, data sharing should be done in theknowledge of the patient so as not to cause
problems. This is because the contents of the
medical record belong to the patient, even though
the electronic file is stored by the healthcare

Eubios Journal of Asian and International Bioethics 29 (July 2019)provider. In Article 26 paragraph (1) of Law
Number 11, 2008 on Information and Electronic
Transactions, it is stated that unless stipulated
otherwise by law and regulation, the use of any
information through electronic media concerning
personal data of a person must be made with theconsent of the person concerned.
To get patient approval, informed consent or
general consent is needed when first getting
healthcare through teleconsultation or other formsof telemedicine. At this stage, the patient needs to
get a full explanation of the benefits as well as thenegative impacts that can occur with the data
sharing including what data and with whom thedata can be shared.
Data protection
Patient data security must be considered in healthservices with telemedicine technology. This relates
to the confidentiality of the patient’s medical record.
Data security and medical confidentiality ofpatients have been regulated in several regulationsin Indonesia such as the Minister of HealthRegulation Number 269, 2008 on Medical Records,
Regulation of Minister of Health in Indonesia
Number 36, 2012 on Secret Medicine, and Law
Number 29, 2004 on Medical Practices.
Telemedicine service providers who are also
providers of electronic systems must carry out
procedures to secure electronic systems in avoiding
interference, failure and loss. This is stated in
Article 20 paragraph (1) of Government Regulation
Number 82, 2012 on Electronic System Operators.
Electronic system providers must also provide asecurity system that includes procedures andprevention systems and countermeasures against
threats and attacks that cause interference, failure
and loss.
Cyberattacks on patient data should be
minimized by increasing cybersecurity. Improving
cybersecurity can be done with periodic network
security evaluation and testing and access
restrictions. Access restrictions are related tohealthworkers and types of data that may beaccessed on a patient’s medical record data.
Healthworkers that may have access patient data
are doctors and other health workers, personnel
related to financing health services, otherpersonnel who have access to patient data andinformation, insurance, legal entities, and medical
students in health facilities.
Strengthening security can be done by using astrong username and password and periodic
password updates or the use of cryptographic
techniques. User and service history should be
stored starting from the date, time and relationshipwith the patient.

129

In addition to data security, data stability also
needs to be considered. As far as possible damaged
or lost data is minimized. This is because theremoval of the patient’s medical record has animportant position in the law that can be used as
evidence as stated in Article 13 paragraph (1) letterc Regulation of the Minister of Health Number 269,
2008 on Medical Records. To avoid missing data,
the provider should back up data periodically.
Distance contracting & electronic signature
Therapeutic transactions are important in healthservices. With therapeutic transactions between
patients and related health personnel, a legal
relationship arises between them with the rights
and obligations of each party. Typical transactions
or contracts require the ability of the parties to theagreement, certain objects, and being lawful. Moredetailed regulations regarding the terms of thecontract are listed in articles 1320, 1332 and 1333
of the Civil Code.
In the doctor-patient relationship in real practicewhen patients and doctors meet face to face,therapeutic contracts can occur in the form of
informed consent or general consent. Informed
consent can happen with implied consent or
expressed consent. Implied consent is a statementof patient consent implicitly without a firm
statement such as a nod or gesture when examined.
On the other hand, expressed consent is a patient’s
approval which is stated verbally or in writing on a
medical action to be taken (Ramugade, 2018)
Telemedicine requires an agreement between
the doctor and patient in both implied andexpressed consent forms. In the case of patientsand doctors who do not meet face to face directly,
implied consent is certainly more difficult toimplement. In addition, in agreement with writing,electronic signatures are needed. Indonesia hasrecognized electronic signatures as verification andauthentication tools. This is stated in Article 1
Paragraph (12) of Law Number 11, 2008 on
Information and Electronic Transactions.
Although performed remotely, a therapeutic
contract between the patient’s doctor must be
made clear. This is because patients also have theright to get quality services and legal protection in
health services.
License & certification of healthcare
professionals
Legality of permits and place of practice must be
fulfilled in health services, as well as services using
telemedicine technology. Health workers andhealth facilities that provide telemedicine services
should have permission. According to Article 2paragraph (2) Regulation of the Minister of Health
Number 512, 2007 on Practice License and130

Eubios Journal of Asian and International Bioethics 29 (July 2019)

Implementation of Medical Practices in order toobtain a license, doctors and dentists must submit
applications to the Head of the District /City Health
Office where the medical practice is conducted.
In addition, a place of practice or health service
facility must also have a permit. This is stated in
Article 36 of Law Number 29, 2004 on Medical
Practice that every doctor and dentist whopractices medicine in Indonesia must have apractice permit. Article 37 paragraph (2) of the law
also states that the license to practice as a doctor or
dentist, as referred to in paragraph (1), only isgiven at a maximum of 3 (three) places.
A review of permits for telemedicine
implementation is needed. This is due to theexistence of a doctoroid phenomenon, namely theexistence of health services carried out by someone
who is not a health worker and does not have apermit. The doctoroid phenomenon is contrary to
Article 73 paragraph (1) of Law Number 29, 2004
on Medical Practices. The rise of this phenomenon
may cause patient anxiety especially regarding
health services with telemedicine technology.
Legality of license to practice is required in
onlinedoctorconsultation
services.
Thegovernment
togetherwithprofessionalorganizations should work together to formulate
regulations that govern them. Practical places andpermits for online practice should be given special
permission and certification with several
procedures that must be fulfilled so that its
implementation can minimize cybercrime that canharm both doctors and patients.
Jurisdiction issues
Jurisdiction issues must be considered in theimplementation of telemedicine. This is because
telemedicine is a health service not limited in
distance and time. Legal problems carried out by
health services or health workers in other countries
can be crucial problems. To bridge this, aframework or regulation regarding telemedicine isneeded internationally (McLean, 2006).
Legal liability
Legal responsibility is the responsibility of healthworkers or health services if legal problems happen.
The problem of responsibility can become an issue
if not addressed wisely. In the case of telesurgery(remote surgery) with the help of assisted robots,for example, if an error is made during surgery,
who will be responsible? Is this the responsibility ofthe surgeon? Or is it included as a device or robot
assistant error? Can the surgeon be prosecuted if
there are legal problems?
Therefore, the problem of medical device
standard is important and related to legal
responsibility and determination of malpractice. In

addition, in teleconsultation it is also necessary toagree on legal responsibility between healthworkers and health facilities that provide healthservices.
For third party users in the development oftelemedicine,
agreements
regardinglegal
responsibility are also needeed, especiallyregarding data security and confidentiality issues. It
must be agreed whether in a data leak and data
damage, the third party or health personnel is
responsible or the related health facilities are
responsible.
E-prescribing
Teleconsultation between doctors and patients canlead to online prescribing known as e-prescribing.
E-prescribing will be written by a doctor in theform of electronic data and then forwarded to thepharmacist who will process the electronicprescription (Amber et al, 2014). E-prescribing
plays a role in telemedicine technology, especiallyin teleconsultation processes that connect patientswith health workers. E-prescribing has several
advantages
including
reducing
errorsinprescription writing and determining drug doses,
accelerating prescription acceptance, adherence todrug formularies, identification of dosage errors
and drug allergic reactions, improving service
quality, and reducing malpractice claims fromdoctors due to medication errors is prescribing
online (Annie & Annesha, 2014).
Although it has many advantages, and isnecessary to control the quality of e-prescribing
services as needed. The Drug Enforcement Agency(DEA), an institution that controls drug distribution
in the United States, issued regulations relating to
the certification of e-prescribing service providers(Drug Enforcement Agency). In addition, the eprescribing procedure is regulated in special
regulations so that no drug abuse occurs through eprescriptions. Online prescription, especially for
drugs that are categorized as narcotics, must be
closely monitored and there are special regulations
that govern them, especially if doctors and patients
have never met directly before.
Indonesia has problems with telemedicine
implementation, especially teleconsultation with
online prescribing. This is because Indonesia does
not yet have adequate health technology to replace
physical examination and provide remote support.
Examinations without physical examination or
supported by recommendations do not provide
optimal diagnosis and therapy results. Differencesin diagnosis or misdiagnosis are very likely to occur.
According to a study conducted by Eedy & Wooton
in 2001 regarding teledermatology, there were
33% of teledermatology cases that experienced adifferent diagnosis or misdiagnosis with a realEubios Journal of Asian and International Bioethics 29 (July 2019)
examination (Eedy & Wooton, 2001). This situation
contradicts with the patient’s right to obtain quality
health services not harming the patient.
Online prescribing may be applied to teleexpertise models or teleconsultation models forpatients who have met a doctor before and havemedical record records at the healthcare facility. In
tele-expertise, the doctor or expert who receives
the consultation will only give advice or therapeutic
recommendations while prescribing is carried out
by health workers or doctors who are dealing
directly with the patient. On teleconsulting patients
who have received treatment at the health facility,
teleconsultation can be carried out in order toobtain further information or monitoring of thepatient’s condition.
However, in teleconsulting online prescribing
should be limited. Health services in the form ofproviding health information are considered safer
compared to establishing a diagnosis and therapy,
especially if there is no supporting technology tocarry out physical examination and remote support.

Conclusion

Based on the description in the previous sections it
can be concluded that telemedicine is a technology
in the health sector that may be very useful if
implemented in Indonesia. However, special
regulations are needed to regulate theimplementation of telemedicine so that it is notcontradictory with ethics and laws in Indonesia.
The regulations can include definitions oftelemedicine, electronic medical records, dataprotection and privacy, legal responsibility,
standard medical devices, e-prescribing, andjurisdiction issues.

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Amber Porterfield, et al. 2014. Electronic Prescribing:
Improving the Efficiency and Accuracy of Prescribingin the Ambulatory Care Setting. Perspect Health Inf
Manag. 11; 1-21
Andrew J, et al. 2018. Telementoring and Telesurgery for
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199 (2), 355-369
Anissa L, Menaldi SL. 2015. Aplikasi Telemedicine dalamMerujuk Pasien dari Daerah Rural. Jurnal KedokteranIndonesia 3:220–4
Annie Hahn & Annesha Lovett. 2014. Electronic
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Eedy DJ, Wooton R. 2001. Teledermatology: a review. Br
J Dermatol. 144(4): 696-707.
Gersak B, Gorjup V, Jazbec A. 1999. The telemedicine andsecond opinion. Stud Health Technol Inform, 68;245-6
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Isabelle Andoulsi. 2010. Telemedicine Legal Challenges.
European Telemedicine Conference. Italy, 7-8 October.
Laws of Malaysia. Act 564; Telemedicine Act 1997.
Mable Kekana, Pitso Noe, Boyce Mkhize. 2010. The
practice of telemedicine and challenges to theregulatory authorities 3, (1) SAJBL.
McLean TR. 2006. International Law, Telemedicine, andHealth Insurance: China as A Case Study. Am J Law
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Minister of Health of the Republic of Indonesia Decree
Number HK.02.02, 2016 on Trial Hospital of Videoconference and Teleradiology-Based Telemedicine
Service Program
Minstry of Health in Indonesia. 2017. Health Technology
Assessment Guidebook: Clinical and Evaluation
Effectiveness.
HealthTechnology
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Committee Jakarta,
Ramugade MM. 2017. Legality of Consent in Todays
Dental Practice. International Journal of Current
Medical and Pharmaceutical Research. Volume 3, Issue
5; pp 1681-1683
Tensem E, et al. 2016. Two Decades of Teledermatology:
Current Status and Integration in National Healthcare
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World Health Organization. Telemedicine in Indonesia:
Country Experience. Pyongyang, 30 July 2013.

We invite contributions for a new bookfrom Eubios Ethics Institute: Legacies ofLove, Peace and Hope: How Education canovercome Hatred and Divide.
https://www.eubios.info/legacies_of_love_peace_and_hope

We welcome persons and collaborators tocontribute papers, and also to join a launch
conference of this book in Christchurch at someday between 25-29 September 2019.
Please email to Prof. Darryl Macer,
Email: darryl@eubios.info

132

Eubios Journal of Asian and International Bioethics 29 (July 2019)

Youth unemployment in Nigeria: A
failed state argument- Galadima Gladstone Wayas, Sivapalan Selvadurai,
Abd Hair Awang
Centre for Development, Faculty of Social Sciences andHumanities, Universiti Kebangsaan Malaysia
Email: sivap02@gmail.com

Abstract

Youth unemployment in Nigeria is alarming. It
increases annually, coupled with the increase in thenumber of higher institutions in Nigeria that
produce many graduates yearly. The resultant
effect on the Nigerian society is an increase in social
vices. This situation of youth unemployment serves
as an obstacle to economic, political and social
development of the Nigerian state. Youthunemployment leads to high rates of poverty
among the youth, and poverty in return has
negative implications on the social well-being of the
youth. It can lead to psychological effects, forexample frustration. This study examines thecauses of youth unemployment in Nigeria. The
study relies solely on secondary sources data andpresents its analysis in the context of the Failed
states’ theory. The findings reveal that the failureof the state to provide a proper school curriculum,
corruption among public office holders, lack of an
enabling environment for economic activities aresome of the causes of youth unemployment in
Nigeria. Due to the aforementioned causes of youth
unemployment in Nigeria, the study recommends
the state is duty bound to provide among otherthings more vocational and skills acquisition
institutions as well as to enforce adequate
governance to instill integrity. More so, priority
should be given to security by the government as away of attracting foreign investors to Nigeria.

Introduction

Youth unemployment according to International
Labor Organization (ILO) is a threat to the growthand stability of different nations of the world (Kale2012). Available records from the World Bank
reveal that the unemployment rate in Nigeria wasat 22% in 2012, while the youth unemployment
rate was at 38% and it also reveals that not lessthan four million Nigerian youths go into labormarket every year and that the unemployed
number increases yearly (Subair 2013). As a resultof unemployment, many youths developed aplatform of criminal attitudes and tendency as away of attaining to their needs through armed
robbery, car snatching, pipeline vandalization,
prostitution, and other criminal acts (Dabalen et al.
2000). Armed robbery, political thuggery,

kidnapping, Boko Haram, and other criminal acts
among youths are identified as consequences ofyouth
unemployment.
Thesituationofunemployment in Nigeria is more complex due tothe global economic recession that has made it
almost impossible for youth employment (Suleiman& Aminul Karim 2015). It is evident that the highrate of unemployment is a factor for the underdevelopment of Nigeria. Some of the youths who
are unemployed have probably turned themselves
to suicide bombers due to frustration, vandals,
terrorists, kidnappers, militants, armed robbers,
and lots more, thereby causing Nigeria a great loss
in revenue earnings, which in turn hinders her
development as these problems have a negative
impact on the economic, political and social aspectsof the development of Nigeria directly (Kale 2012).
In addition to this set of youths, the uncountable
millions who are not in employment, education andtraining (NEET) added to the ones that may notseek for menial employments or be involved in theinformal employment have joined the evil gangs ofarmed robbery and kidnapping (Chiazor & Udume
2017). This great number of the unemployedyouths have become mighty tools in the hands ofwicked persons who use them for their selfish
interest either as political thugs or use them tocause crisis in the nation (Baah-Boateng 2016).
There are various reasons associated with
unemployment. Besides demographic factors
namely population growth and rural-urban
migration generating the youth cohorts, often thestrength of the economic factor namely the
manufacturing economic activity (Freeman & Wise
1982) are attributed together with social
dislocations
associatedwithneoliberalism
argument (Okafor 2011)..
However,indeveloping
countries
theinterdependence of market economy on the role ofstate is critical as the markets are not welldeveloped and the penetration of capitalist
economy that generates investment for job creationis still at an infancy stage. This study examines thecauses of youth unemployment in Nigeria byarguing that the state has failed in its fundamental
duty in playing an enabling role for the flourishingof its economy. This research adopted qualitative
methodology with descriptive analysis. Its data arefrom secondary sources, mostly journal articles,
books, reports from recognized internationalorganizations like the ILO and NBS. Others are theAfrica Bank, OECD and online resources.
Youth unemployment
Youth unemployment could be defined as asituation of young people living without an engaged
job to earn a living. The International Labor
Organization considers it as the entire population

Eubios Journal of Asian and International Bioethics 29 (July 2019)of able people living in a society that were
supposed to be part of the economically active
people but are living without employment and arealso willing and available for work (Olawoyin 2017).
The implication of the above definition is thatunemployment is the number of working age
people between the ages of 18 and 60 years as
stipulated by Nigerian constitution, who aresearching and available for employment within astipulated or given period. It is not just a workableage of people without work, but people that areinterested and are actively searching and areavailable for a job. Such an individual is duly
qualified for gainful employment and has madeseries of applications or attempted different
recruitment opportunities but could not
successfully secure any job (Okafor 2011).
Youth is being seen and defined differently bydifferent societies of the world. The United Nations
considers ages between 15 and 24 as youths, while
Uganda considers ages between 12 and 30 asyouths. Youth is best understood as a period oftransition from dependence childhood to adulthood(Akande 2014). Youth in Nigeria is regarded
between the ages of 18 and 35 years. The National
Youth Policy document of Federal Republic of
Nigeria stipulates the following characteristics foryouths: He must be a Nigerian citizen between theages of 18 and 35 years old, must have completed
secondary school education, tertiary education, or
learning a trade, he is looking for employment oralready employed, he is leaving parental homebecause of marriage or being independent(Abdullahi et al. 2014; Osakwe 2013). In its 2017
statistics on youth unemployment, NBS (2017)
reported of Nigeria having 61.6 percent youth
unemployment. The same record reported of
Nigeria having 97 million as the national populationof the youths. Based on this report there was fearover the high rate of both the youth population andtheir present unemployment status as he felt youth
unemployment population may constitute an armyof a revolution or may stage revolution one day due
to their poverty level and frustration (Ugwu 2017).
Youth unemployment as a global challenge, ismore severe and challenging in developing rather
than developed countries. A research conducted by
UK scholars indicated Portugal had 24% as its
youth unemployment rate, and UK had 12% as their
youth unemployment rates. In the summary reportof the study for European states, it indicated theCzech Republic has 7 percent as the lowest
unemployment rate followed by Germany with 9
percent while Greece has 44 percent as the highest
unemployment rate and Spain followed with 39
percent within the Euro region. The data also
reveals that female unemployment was 9.2 percent

133

and male was at 8.9 percent (Dietrich & Möller
2016; Mcguinness 2017).
In 2001, the United Nations General Assembly
portrayed almost the developing states as weak andfailed nations due to their inability of improving
their economic, youth unemployment, security, andpolitical stability. As a result of their deficiencies,
terrorists and insurgencies activities thrive in theirnations as many of the deprived citizens like theunemployed youths would choose to join unethicalways and criminal groups to earn their living. The
UN concluded that with their high rate of youth
unemployment, illiteracy, and poverty most of thedeveloping states served as fermentation tanks forterrorists and other insurgencies (Azeng & Yogo
2013; Piazza 2006, 2008).
Youth unemployment in Africa has been aserious challenge as it increases yearly coupledwith its related problems of criminal involvement
in an attempt by the unemployed youths to meettheir needs. Idris (2016) reported healthy andqualified young persons living without employment
are easily lured into unethical ways of getting theirneeds met. Their situation is not just a threat to theleadership but the entire society of Africa. The samescholar reported that though there was global
youth population explosion but the population in
Africa was not commensurate with employment
opportunities. The implication is that birth control
was not done or was not taken seriously in Africa asregards to an expected number of children a family
ought to have based on the strength of theireconomy (Bello & Yacim 2012; Idris 2016).
The report indicated African states had thehighest youth unemployment rate among thenations of the world. North Africa in 2015 had 30
percent unemployment for male and 45 percent for
female youth. The report added their situation was
indeed pathetic as a great number of their youths
were not in education, employment, nor training(NEET). The situation in Tunisia and Egypt was
worrisome too as young persons between the agesof 15 and 29 were not in education, employment,
or training (NEET).
Their NEET percentages were 32 and 40
respectively (Assaad & Roudi-Fahimi 2007)(Fenwick & Van Goethem 2017; Karimova &Manrique 2018).
Available literature shows that African states
have the highest rate of youth unemployment in theworld. More so that the low rate of youth
unemployment among Europe and most East Asian
economies emanate from their proactive strategies
towards curbing youth unemployment. This study
is prompted by the worrisome situation of youth
unemployment in Nigeria because available
literature did not critically analyze the Nigeriansituation. For this reason, the study took a

134

Eubios Journal of Asian and International Bioethics 29 (July 2019)

departure from the previous studies to investigate
the causes of youth unemployment in Nigeria.
Failed states’ theory
A state or a country is a sovereign and politicalentity with specified and recognized boundaries or
territory with its governmental institutions, andcan have its democratic leadership for adequate
supervision and purposive administration fordevelopment. The state therefore, is seen or
regarded as a provider of services to its citizens, orthe state has fundamental responsibilities to its
people, for that is the purpose of its existence(Zartman 1995). The implication of the descriptionof a state as a provider of services to its citizens
according to the theorists (Rotberg and Zartman),means a state ceases to being when it fails in its
fundamental responsibility of providing services to
its citizens (Rotberg 2010). The theorists
considered security of lives and property as the
major and fundamental service a state should
provide for its citizens. Others include
infrastructure and social services, the rule of law,education, employment and health (Rotberg 2003).
The assumption of this theory is that a state is nolonger a state when it fails in its basics andfundamental responsibilities for its existence. Its
failure is not only seen in its inability to provide
infrastructures, employment, or services to its
citizens, but it is also seen in its deficiency tocontrolits
territorialboundary
andmisappropriation of the state power to thedisadvantage of the citizens. A failed state, due to its
deficiencies is highly threatened with terroristgroups, insurgencies and other related criminalgroups within its territory. As such it hardly
embarks on any economic and developmental
policies as its attention has been taken by problems
it created due to its deficiencies (Zartman 1995).
This theory is chosen to explain the causes ofyouth unemployment in Nigeria due to its
peculiarities to Nigeria’s present situation, where
unemployment, insecurity, and criminal cases areon the increase on a daily basis as government has
failed in its responsibility. The powerlessness of
Nigerian leadership in providing employment for
its unemployed young persons and insecurity has
provided abundant atmosphere or situation forterrorism like the Boko Haram, kidnapping, andother related crimes.
The description of a failed state by the theorists
is indeed a perfect glaring picture of Nigeria’spresent situation whereby security of lives andproperty is never guaranteed for the masses(Chiazor & Udume 2017). It was stated thatbetween 2009 and 2011 more than 140 nonnationals were abducted by Nigerian youths. Theircriminal actions crippled businesses and enlarged

the number of youth unemployment and terrorism
as the atmosphere was not safe for commercial
activities and businesses, while numerous
businesses crumpled and several schools shut
down in the North East of the country (Adedeji¹ etal. 2018).
The incapacity of Nigerian government toprovide infrastructure, facilities, and miserable
nature of power supply to the people in theirstruggle to remain in their businesses or selfemployment aggravated their situation to theextent the same self-employed individuals like thealuminum window makers, welders, furnituremakers, fashion designers, and the related selfemployed persons or Nigerians folded up theiractivities as they were not able to buy personal
generators or could not afford power generators(Ruth et al. 2014). The theory is most relevant anduseful in explaining the causes of youth
unemployment in Nigeria and the related social
problems as it is a byproduct of a failed state ofNigeria.
Table 1. Youth unemployment trends in Nigeria
between 2010 and 2014
2010
21.1%
2011
23.9%
2012
24.3%
2013
28.5%
2014
30.0%
Source: Adopted from Innocent (2014)

Table 1 shows youth unemployment rate in
Nigeria increases yearly. This could be due to anumber of factors connected to leadership thatfailed in its basic responsibility of providing
employment and other services for its citizens.
Causes of youth unemployment in Nigeria
Nigerian youth unemployment is the consequenceof a series of factors that reflect the failure of thestate to account for its responsibility namely:
ccorruption, improper school curriculum, and lackof enabling environment for businesses.
1- Corruption
Corruption as a major factor responsible for youth
unemployment in Nigeria. It may not be explained
and measured easily; however, it is easy to be seen
and identified as evil or bad behaviors (Idachaba2014). Asian Development Bank sees corruption as
wrong, bad and illegal behavior of public or private
sector officers to favor and amass themselves withpublic resources and equally do the same torelations and friends, using their positions to
influence others in illegal ways to the detriment of
the general public (Oecd, 2008). It could beconsidered as non-violent criminal practices andEubios Journal of Asian and International Bioethics 29 (July 2019)illegal manners or activities with the aim to acquire
wealth or resources meant for the individuals or
the public (Adedeji¹ et al. 2018).
Corruption is therefore most responsible for
Nigerian youth unemployment as it is the evil or
illegal actions of men and women at the
management of resources that has brought Nigeria
to this present level of high youth unemployment(Okorie 2014). The officers who are legally
appointed for the good of the public, use their legal
or authorized offices or positions for personal
interest that in most cases involve stealing publicfund meant for developmental purposes andcreation of employment opportunities. This illegal
way of such officers could involve manipulations of
figures and information to favor some persons
instead of being neutral in the discharge of their
responsibilities as stipulated by the civil service
rules that government officers should be neutral inhandling their assigned duties (Samuel 2011).
Corruption as an illegal way of taking what
belongs to others, especially the general public ispracticed by individuals or private sector in Nigeria.
Tax evasion and tax avoidance are major issues in
corruption, and could be best described as deceitfulmanner of paying taxes to government through aseries of mechanisms. The essence of this is tomake money for themselves and their companies(Palan et al. 2013). The negative effect of thefraudulent activities of paying less taxes or none to
the government, deprives the government ofadequate resources needed for the societal
development and provision of infrastructure andcreation of employment opportunities (Otusanya2011).
2- Improper school curriculum
Nigeria’s educational system is seen as a major
factor responsible for youth unemployment in the
country. Nigeria educational system is indeed afactor responsible for youth unemployment
because the curriculum planners failed to include
issues that are related with the changing
environment to make the Nigerian youths
employable after graduation from school. One ofthese is computer literacy knowledge that isneeded globally for effective and maximum
performance in all disciplines of life. A lot of
Nigerian youths are not computer literate, thoughmost of them are graduates from different
universities of the nation. This therefore makes it
almost impossible for such graduates to get
employment these days particularly withinternational organizations in Nigeria (Ajake et al.
2014).
Added to this problem is that most of theinstitutions are not well equipped to provide theyouth in schools or under training the expected

135

knowledge they require for employment. For
example, many youths who study business inNigerian universities and other institutions of andwould be expected to be employed as secretaries or
accountants and business administrative officers
can hardly type or work and operate a computer
due to the inability of government to equip suchinstitutions with computers and manual typewriters for the sake of skills acquisition (Collins &Halverson 2009). This is an indication that Nigeria’s
current educational curricula are not appropriate
for the present needs and realities of life (Kareem
et al. 2016).
The present curricula for Nigerian schools or
educational system do not lay much emphasis andpriority on entrepreneurship or entrepreneurial
skills acquisition with the hope for selfemployment. Instead youths are given an
orientation during their trainings of seeking
employment with the public or private sector after
completion of trainings (Etodike et al. 2018).
Vocational and technical education training as asolution to youth unemployment is not given apriority in schools’ curricula in Nigeria (Edokpolor& Owenvbiugie 2017).
The major role of vocational and technicaleducation training skills is that it equips the youths
with the desired skills for self-employment and toenable them to participate in the developmental
processes of their nations. Both the developed andsome developing nations have identified vocational
and technical education training skills as the bestsolution for youth unemployment and for thedevelopment of a society (Edokpolor &Owenvbiugie 2017). Added to the above reasons ofyouth unemployment, a scholar stated it clearer
that the growing youth unemployment rate in
Nigeria is an indication or expression that the huge
number of youths do not have the skills to initiate
and operate a business so as to become selfemployed (Olajide 2015).
3- Lack of enabling environment
Nigeria’s failure in providing an enabling
environment for successful business and economic
activities, coupled with infrastructure utility power
failure is also responsible for the increasing rate ofyouth unemployment. The environment is notindeed safe for any reasonable economic activities;
neither does it attract external investors due to theactivities of Boko Haram, kidnapping, herdsmen
killings, and corruption among the public officeholders. It was reported that more than one
hundred business organizations in Nigeria thatprovided employment for thousands of Nigerians
closed down between 2009 and 2016 as a result of
unfriendly nature of the environment as statedabove and lack of adequate power supply.

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Eubios Journal of Asian and International Bioethics 29 (July 2019)

The closure of some of the businessorganizations in Nigeria within these years
eventually brought their staff to a state ofunemployment. Other youths that completed theirtrainings in their respective institutions and tradecenters had nowhere to go for employment or toapply for jobs (Chiazor & Udume 2017). The
inability of the government due to corruption toprovide infrastructure and facilities, and poor
nature of power supply to ease the citizens in theirefforts to continue with their businesses or selfemployment aggravated the situation to the extent
that self-employed persons wound up theiractivities as they were not able to buy personal
generators or could not afford the power
generators (Ruth et al. 2014). Apart from theartisans that closed down their self-employment,international business organizations in Nigeria likethe Michelin, Dunlop Plc, Volkswagen Plc, PZ, etc
also closed down their operations for the state’s
inability to provide them with adequate power
supply needed for their operations in Nigeria. They
therefore relocated to other nations with stable
power supply and peaceful conditions in suchnations. The multinationals departure or exit from
Nigeria resulted in more than two thousand
unemployed Nigerians to the already existing ones
(Borjas & Van Ours 2010; George & Oseni 2012)Conclusion & recommendations

With the available records on literature, youth
unemployment is both a peril and obstruction to
the development of many nations of the world. It
constitutes economic, political, or social problems
and also affects the unemployed youths
psychologically as it renders them frustrated andpowerless due to hopelessness and distress that
may lead many to commit suicide and other social
ills. The failure of the state to provide improperschool curriculum, corruption among public officeholders, and lack of enabling environment foreconomy activities are some of the causes of youth
unemployment. The failed state argument contrasts
with the neoliberalism argument which accounts
for institutional constraints of developing
economies like Nigeria.
Youth unemployment is a serious problem in
Nigeria that needs urgent attention due to its effectthat is degrading and under developing the nation.
It is against this background that the following
recommendations are put forward as measures forcurbing the challenges of youth unemployment in
Nigeria. Government should intensify efforts tocreate more vocational skills at acquisition
institutions and centers across the country toenable young men and women to acquire skills foreasy employment and to be self-employed. Skills
acquisition is a strong instrument for

empowerment of youths in areas like tailoring,carpentry, automobile mechanic, ICT, metal work,
to mention but a few.
Educational systems should be restructured andequipped to meet the needs of the changing
environment and globalization as well as equipping
the youths with entrepreneurship and vocational
skills for self-reliance. Agriculture should be given apriority by the government and policymakers; thiswould not only feed and provide income to thepeople but provide employment for the youths inrural areas and reduce the rural-urban migration.
Security should be made available by thegovernment as a way of attracting foreign investors
into the Nigerian society. Besides that, the stateshould enforce adequate governance to instill
integrity and eradicate corruption. Also improving
the provision of adequate power supply in majorindustrial and commercial centers will attract
investors. Setting up business organizations andindustries by foreign investors would go a long way
in reducing youth unemployment, crimes, andpoverty in the land as employment would be
provided for citizens.

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A review of women’s intellectual
contribution under thebureaucracy in Pakistan- Salman Ahmed Khatani
Department of Business Administration, Iqra
University, Karachi, Pakistan- Ghazal Khawaja Hummayun Akhtar
Department of Public Administration, University of
Karachi, Pakistan
Email: gkhawaja@uok.edu.pk

Abstract
This paper is divided into three parts. The first partprovides an overview of literature on the factorsthat restraint women’s intellectual contribution in
Pakistan’s bureaucratic setup, specifically in thedepartment of foreign affairs. The second partexamines the root cause of sociocultural dilemmas
that rule out the role of women in Pakistan’s
bureaucracy. The third part provides the argumentthat Pakistan’s bureaucracy is not gender neutral
and by consequence not Weberian (Evans andRauch, 1999).
Women’s omission from the department offoreign affairs“No nation can rise to the height of glory unless
your women are side by side with you; we are
victims of evil customs. It is crime against
humanity that our women are shut up within
the four walls of the houses as prisoners. Thereis no sanction anywhere for the deplorable
condition in which our women have to live. You
should take your women along with you as
comrades in every sphere of life.”(Muhammad Ali Jinnah, 1944)
Table 1 Women’s intellectual contribution
Particular
Total
Men
Women
Foreign Minister
26
25
1(1947-2013)
Minister of State
09
09
NIL
(1973-2013)

Foreign Secretaries
28
28
NIL
(1947-2013)
Foreign Service
1143
909
234
Academy alumni (19832012)
Source: official website www.mofa.gov.pk Compiled bySalman Ahmed Khatani

According to facts and figures shown in Table 1,
the respective department did not follow the policy
statement of Quiad-e-Azam about women’s
intellectual contribution. Inheriting features of apatriarchal society, this department is always
headed, administrated and run by men. Though instated policy of this department it has been clearlymentioned that the rule of equity and equality shallprevail.
Spanning from 1947 only one woman secured
the position of foreign minister compared with 26
men in that period. Meanwhile, the situation under
the state ministers was not in any better shape than
the former; from 1973 onward, not a single woman
with said portfolio was seated, never also a female
foreign secretary served in the entire history of
Pakistan. The negligible number of professional
cadres produced by the respective academies also
pictures the sorry state of representation of womenin the foreign office of Pakistan.
Foreign policy objectives of Pakistan
According to the stated policy of Foreign Service
Department under the Vision of Father of Nationand per constitution of Pakistan, The Muslim
Family Laws Ordinance, 1961:3“Equality of status,
equality of opportunity, equal pay for equal workand guarantee of rights for Muslim women under
the Muslim Personal Law of Shariah” were a part of
the Charter of Women’s Rights, prepared by Begum
Jahan Ara Shahnawaz.4 The Charter was passed by
the Constituent Assembly with an overwhelming
majority. One key focus of foreign policy is,“ensuring optimal utilization of national resources
for regional and international cooperation5.”
But unfortunately, in the first decade (19471958) of independence, this newly born country
had faced a discriminatory behavior and pattern inpolicy. This was contrary to the basic policy
statement that was laid down. The reason behind
this pattern was that during the first eleven years of
independence, six Prime Ministers came to power
3 See the text of the Ordinance in the Gazette of Pakistan(Extraordinary), March, 2. 1961
4 Anis Mirza, “Women’s Role in the Pakistan Movement
and the Formative Years”, paper read in the Soroptomist
Club Seminar “Women in Public Life, October, 1972
Lahore” p.4. This Front was particularly active in Karachi,
which was then the Capital of Pakistan.
5 official website www.mofa.gov.pk

Eubios Journal of Asian and International Bioethics 29 (July 2019)
one after another with eight cabinets whose
members were all male. Never ever any female wasselected or nominated in any Cabinet with any
portfolio or designation during this era. Naturally
this pattern expedited its repercussions on thesubsequent offices that came under different
ministries and portfolios; the foreign affairs
department inherited this pattern where thesupremacy and advocacy of men prevailed as
gender bias.
These brief historical facts are opposite to thestated policy objectives of Pakistan. But thequestion is why the stated policy could not be
followed, and what were the reasons that restrain
women’s intellectual contribution to the concerned
departments. In the second part of this paper wewill look in detail at the sociocultural norms andtaboos that are the root cause of these unjust anddiscriminatory roles. This part will examine theroot cause of sociocultural dilemmas that rule out
the role of women in Pakistan’s bureaucracy.
The missing piece of jigsaw, the identity…
Societies have been governed by unwritten social
codes, which were highly respected and expected to
be followed by every member of society. These
unwritten rules have greatly contributed topreserving the romantic image of marriage andmotherhood, an ideological device functioning toentrap women into accepting an unfulfilling andlimited role in every walk of life.
Women are always depicted as “motherswomen”. She gives birth to many valuable offspring.
One who always gives herself up completely,
without hesitation, both spiritually and physicallyto her family; such a character, a woman who isaware of and accepts her role as a sacredmother/wife figure imposed on her by society. She
can only see herself within the frames of the
traditional mother role, or a devoted daughter or awoman who is a sister to a brother. Even
behaviorists used romantic and fairytale imagery togive her a romantic aura that instantly separates
her from being a natural human being more thanany other role. She is confined to many other roles,
suppressing her emotions, leading her own soul
torn apart with these roles quarrelling with eachother. The misunderstanding between the twosouls is an example of the conflict between
individuality and culturally based perceptions.
Through women’s roles as mothers or wives, they
become “symbolic bearers” of the collectivity’s“identity and honor” and are often required to carry
this “burden” of representation which restrains
women’s intellect at every walk of life. Since she
could never give up herself - the true essence of her,a woman would give her life for her children, but
couldn’t give herself more and that’s why she lacks

139

professionalism. It’s something which may only becomprehended as a severe identity crisis, which is infact the total absentia of her one true identity that ishumaneship.
The
prejudices&oppressions
inbureaucracy
In order to understand the historical oppression of
women in bureaucracy, we have to understand not
only the physical dimension such as extortion andman handling but also the shameful practices
especially those concerned with constructions ofidentity that have questioned the roles affixed tothe male and female identity. We have also sought
to show how these roles interplay with the total
bureaucratic setup; the dichotomies apparent in
identity-construction can also be found in thedivision of bureau realms, where men’s “natural” or“determined” role is found within the public sphere,
and that for women is found within the private
sphere. The subject area of reproduction rights andresponsibilities has historically not been given highpriority within the political realm and inbureaucracy which can thus be explained throughthe idea that “women’s issues” are private issues
and thus do not belong in the official political publicsphere.
The first theme explored relates to the notion of
women’s identity within the bureaucratic context,
where the focus is on how women’s identities cometo serve particular interests in relation to theinterest of the nation. Women’s roles within theprivate sphere are then seen to be constantly
reinforced as they legitimize their position in thenational collective. The second theme deals withthe dichotomy of Law versus Victimization. Here,the focus should be on how this dichotomy is fitted
within the construction of women’s and men’s
identities; where women often need to beconstructed as “victims” in order for her actions orrather non-actions to become comprehensible. The
third theme questions the context of choice thatwomen are offered within the abortion discourse.
Here the analysis is discussed and thus a specificcontext is produced in which the issue can behandled.
Responsibility or confinement …
Women’s “natural” position within the family is also
important to highlight since the role stands in an
opposed relation to the roles assigned to men.
Many argue this matter by showing how women’s
identities are often constructed so that they
contrast with values associated with men: it isreflected in our values by the way of assigning
women’s roles within the bureaucracy. This leaves
the impression that the role of a mother or wife isin fact her given role in society. The responsibilities

140

Eubios Journal of Asian and International Bioethics 29 (July 2019)that this role entails can thus be “best” handled byher since she has “always” handled these issues andthus cannot contribute to anything professionallybecause she is not able to. This leads to a very
deterministic understanding of women’s and men’sroles in society. By ignoring these oppositional
relations and the significance of values attachedspecifically to women and men, the delegation
indirectly decides who has the greatest power
within bureaucracy.
An honor, a shame…
Some women live in constant fear in bureaucracy.
They live in constant fear because they could havetheir spying brother as their worst enemy, theirmother as a tyrant and their father’s honor
depending on how they behave socially. A woman
ought to obey the norms that exist in bureaucracy
otherwise she could be forced to marriage withsomeone, abused or murdered. Hence, within thisenvironment it is not uncommon that crimes ofhonor could be seen as heroic deeds and carried out
in a predetermined sense. Therefore, there has
always been strong ambition to give a theoreticalperspective that these violations are created bydifferent social attributes of honor vs. dishonor,
control,
shame,
genderandreligiousinterpretations that also could be based on aspectsof tradition and heritage. Even though women have
lived in a multicultural society as in developed
countries, they have been murdered in the name ofhonor by their relatives. According to United Nation
estimations around 5,000 women are killed
annually worldwide in the name of honor, out of
which 600 were killed in Pakistan in 2003
(Ghanim).
The exact number of women that have been
exposed, affected or victimized by crimes of honor
is not known, neither internationaly nor in Pakistan.
It is evident within crimes of honor that strong
elements of ethnicity, heritage, tradition andreligious interpretations do oppress females thus
reflecting on discrimination within bureaucracy.
The victims of these crimes ought to be given
support and aid, but there is no specific law orconvention that actually gives its support; hence
the legal remedy comes from relevant regulations.
Consequently, the support and punishment that isgiven could be limited; in a sense where it is
misdirected and wrongly carried out. Thus, it isunfavorable for those women who need a good
support. Still, it is not only legislation and some
aspects of the support that need to be extended;
people’s mind needs to change too.

Gender blindness in bureaucracy ofPakistan
One can conclude that bureaucracy in general andforeign affair offices in specific are patriarchal andleast gender sensitive. This part of paper explains
the gender blindness in Pakistani bureaucratic
recruitment process and on the basis of this,neglecting the argument made by Evans and Rauch(1999) that Pakistan bureaucracy is gender neutral(Weberian).
The secondary function of women as depicted on
the canvas by the colors of social and cultural
dilemmas show gender inequity in the bureaucracyof Pakistan, with a substantial report by World
Economic Forum’s Global Gap Report 2014 thatranked Pakistan the second lowest country on
overall measures of gender-based bias (World
Economic Forum, 2013).
Weberian framework and gender neutrality
Weberian parameters are considered to form thebasis for professional conduct in Pakistan’s
bureaucratic setup as it has been inherited by the
British Empire in 1947, in which Weberemphasized on equity in promotion, efficiency, andreward among candidates of an organization.
Weber (1968) theorized that a rational, efficientand achievement–oriented bureaucracy mustemphasize objective standards and impersonalrules which would ensure organizational reliability
and predictability. This entails objective,
independent and impersonal decision-making,without the influence of bias, prejudice, selfinterest, or external pressure that would ensure themost optimum decisions. These would ultimately
produce an organization that is optimally efficientand technically superior.
Evans and Rauch (1999) collected a data set from35 countries, constructed a Weberian scale andtested the data with respect to economic growth.
According to their findings, state bureaucracies
characterized by meritocratic recruitment andpredictable rewarding career ladders areassociated with higher growth rates; they conclude
that meritocratic recruitment is the element of
bureaucratic structure that is the most importantfor improving bureaucratic performance. In theirresearch paper Pakistan ranks high on theWeberian scale.
Meritocratic
recruitment&
Pakistani
women
In Pakistan, a woman’s position in life, her
education, her ability to make independent choices
and whom she is to marry are connected throughher living situation, tradition and culture. Ideally, awoman’s living situation, class or caste should notEubios Journal of Asian and International Bioethics 29 (July 2019)
have an impact on whether she is treated as equal
to men in the society, or not. But, during different
stages in life, a woman has to fight to obtain a levelof independence, may be agitated over thesubordinated position of women and especially face
those women who don’t fight for themselves. The
middle class is growing and more women are
getting educated. As a result, in so far as educationis correlated with higher degree of personal
independence, equal rights put into practice arealso improving. Basic education and higher
education seem to be non-optional for women in
the third group. According to their views, they haveto get higher education to ensure that they will not
be subordinate or dependent upon anyone. Having
their own career is very important to them.
Three faces of women in Pakistan …
There are women in top political positions andwomen running grassroots organizations inPakistan. But there are also women who have no or
little knowledge about their legal rights. No one cansay that all women are discontent with theirsituation of living and are obliged to involve
themselves in political organizations or self-helpgroups or in civil service examinations. But it seems
evident that they ought to be aware of their rights
and to be able to speak their mind without fear ofconsequences. There are substantial differences in
how women recognize and exercise freedom intheir daily lives. By dividing women into threedifferent groups their actions can be analyzed as
representative of these three groups.
For the first group of women, the ones living withless privileges having a few or even no years inschool, education is of vital importance but sill
remains very difficult. Access to necessary andenough information to make independent choices iswhat we expect to find in our society. Being
illiterate restricts the life of a woman in many ways,
for example in her ability to gather information, orto be aware of the bureaucratic system.
Women in the second group are literate and haveentered the public sphere through politics where
they think of themselves as representing the voicesof women. Women need other women in political
positions to plead their cause. It is today possible
for a woman to be leader of a slum area and aftersome time to reach a political position where she
can have an even greater influence. The
presumption that only a woman knows the needs ofwomen is shared by many of the women. But theneeds women have, differ depending on theirposition in society. The women in the second groupfight for issues such as those concerning cleanwater, sanitation, work possibilities, and educationfor everyone. In the election campaigns, they turnto voters who would fit into the first group of141

women, those living in slum areas, by promising to
improve their situation and to meet their needs of,for example, clean water. But still to take part incivil service exam and get through it and get a
position in the apex of policy makers in not anagenda for them.
Women in the third group, those with higher
education, are the ones who seem not to be boundto home. In contrast, women in the first and second
group, with lower or no education, have full
responsibility for the household chores. Some ofthem expressed interest in bringing about a change,for example by being able to work or to get
involved in the decision making at home. But totake part in decision making at policy level is evennot their piece of cake. Many things in the daily lifeof women are connected through the culturalcontext they live in. The traditions still live strong
in many areas of society. The spheres of womenand men are clearly separated although they are
becoming more and more questioned andchallenged. Those who challenge the spheres are
women from the second and third group, women
who are politically and cognizably active or have ahigher education, that is, those with the ability to doso. The division of public and private sphere has tobe explored in every case; there have been
manychanges in women’s position among certain
groups of the society, and no change at all in others.
The analysis of the ground realties and cultural
norms rationales shows that meritocratic
recruitment in Pakistan bureaucratic process is notpossible. As mentioned in code of conduct only 7%of positions are offered on merit basis while therest of all on the basis of quotas and allocation as
per constitution. After criteria are fulfilled by thecandidates they all go through a training process
and after that the patriarchal phenomenon comesin act and the deputation process gets generalized
by the institution.
Women, as Kanter (1977) suggests, stay out ofthe power loop. They never get the chance to secure
relatively important and substantial portfolios likesecretary interior, secretary of establishment,
secetry of commerce, secretary of foreign affairs
and chief secretary. To this date never ever any
female got the chance to become the chief secretaryof any province. Women are only offered a deputy
position on relatively less important portfolios like
women’s welfare, etc.

Conclusion

In conclusion, though the literacy rate all over thecountry is low and specifically among women stillsome get the chance to appear in CSS exams andthen to go through the process of selection andinterview. Their count has been fewer and after allof these hindrances when they reach to the142

Eubios Journal of Asian and International Bioethics 29 (July 2019)bureaucratic setup they face discrimination basedon sociocultural dilemmas, religious advocacy, andmale treatment as they want to take all power andauthoritative posts.
To understand the pattern in Pakistan
bureaucratic system, we have to consider the social,
cultural and religious conventional norms thatprevail in the society generally and in bureaucracy
specifically. In Pakistan from the birth of a child thefirst authoritative voice heard by the newly bornbaby is always from a male cleric and the final
funeral of human also is headed and governed bymen. This shows an eve of power, craving for
authority and thirst to cater and control all affairs
by Men. Women fall under the umbrella ofpatriarchal sky.
This is a far cry from the Weberian bureaucracy
espoused by Max Weber, who initially designed thebureaucracy in opposition to the the traditional
practices in operation at that time. At that time
traditional, monarchic, hereditary and feudal
methods were used to hold on to power andauthority (Tanwir, 2014).
Max Weber failed to understand andaccommodate the difference in social and cultural
norms prevalent in societies of different countries
for implementing rules and regulations formulated
and designed by men. Weberian system tries toswap the traditional feudal and patriarchal oriented
system of authority and power by a fair, free,competent and gender-blind meritocratic system. It
can be concluded that Weber “ideal” system of
bureaucratic practices could not and percontinuation of the rationales, would not be, fit for
Pakistan bureaucratic setup. How one can claimthat Pakistan has gender blind bureaucratic setup
with no discrimination against women? Rather thanthat they have been restrained as shown by facts
and figures; there are so many barriers that
restrain women’s intellectual contribution in
Pakistan bureaucracy.

References

David Ghanim, Gender and Violence in the Middle East,
Chapter 3 Crime and honor.
Evans, P. & Rauch, E. (1999). “Bureaucracy and Growth:
A cross-national analysis of the effects of Weberianstate structures on Economic growth”. American
Sociological Review; Oct (1999) 748-765
Kanter, R. M (1977). Men and women of the corporation.
New York.: Basic.
Tanwir, Maryam (2014). Gender Neutrality and the
Pakistani Bureaucracy. Journal of International
Women's Studies, 15(2), 143-164.
Weber, M. (1968). Economy and society, an outline ofinterpretive sociology, edited by Roth, G and Wittich,Bedminster press, New York.
World Economic Forum, (2013). The Global Gender Gap
Report 2013, © 2013 World Economic Forum.

Influence of affluence in the
choice of assisted reproductive
technology and why it warrants a
policy change-Sreejith P. S.,
Multi Disciplinary Research Unit, Government Medical
College Thiruvananthapuram, India-Krishna G.,
Department of Pathology, Government Medical College
Thiruvananthapuram, India- Chandramohanan Nair K.R.
Department of Anatomy, Government Medical College
Thiruvananthapuram, India
Email: chandramohan1964@yahoo.co.in

Abstract

Presently we have a research project onazoospermia and Y chromosome microdeletion in
infertile males of Kerala funded by the Department
of Health Research, Government of India. During
the study in Sree Avittom Thirunal Hospital of
Government
MedicalCollege(SATH),
Thiruvananthapuram, it was observed that theeconomic status of couples influence the decisionmaking process of choosing Assisted Reproductive
Technology (ARTs), hence the study. The study wasstarted on March 2017 and selected 202
azoospermic males from the semen analysis
registry of SATH. Personal interview method was
adopted for collecting demographic data. The
principal investigator detailed the ethical, financial
and scientific basis of the study to each participant
and consent was taken. In the present study, it wasobserved that the financial status, education andnature of job have a bearing on pursuing infertility
treatment, the choice of selection and attitudes
towards the treatment. Money is a limiting factor
for a majority while moving to advanced treatment
options. The government must include infertility
under the public or private insurance schemes
since the cost of ART treatments are not covered
under health insurance. Finance is a major limiting
factor for pursuing expensive ART methods for the
economically marginalized patients.

Introduction

Infertility is “a disease of the reproductive systemdefined by the failure to achieve a clinicalpregnancy after 12 months or more of regularunprotected sexual intercourse” (WHO, 2013).
Studies show that among all infertility cases, morethan 30% are due to male factors, >35% are due
to female factors, and >40% are due to problems inboth. In 10-20% of cases, no cause is found, defined
as idiopathic (ART fact sheet 2014).

Eubios Journal of Asian and International Bioethics 29 (July 2019)
Infertility affects 15% of the reproductive aged
couples worldwide (Sharlip et al, 2002). The
inability to conceive a child is the source ofsignificant personal suffering to millions of couples
around the globe. Assisted Reproductive
Technologies (ARTs) are established treatment
options for male and female infertility. As the nameimplies, ART will assist or support the patient tobecome pregnant or to become parent of a child.
The commonly available ARTs are depicted below(Figure 1).
The number of patients seeking infertility
treatment is escalating worldwide and the cost oftreatment is also on rise making it unaffordable to alarge number of couples. Even after the World
Health Organization (WHO) and International
Committee Monitoring Assisted Reproductive
Technologies (ICMART) have defined infertility as a“disease” of the reproductive system, the insurer’s
and patients view regarding insurance for ARTs stillholds ethical and policy apprehensions. Since thebirth of the first in vitro fertilized (IVF) baby 40
years ago, ARTs are not covered fully by the
insurance companies. Like most of the countries, inIndia also ARTs are not covered under any of theinsurance schemes of the government or private
agencies. In general, the direct costs for ARTs andthe laws and regulations pertaining to insurance
coverage vary widely in different countries, butubiquitously it has certain pindowns.

143

determining factor for the choice of ART treatment,
prompting us to investigate the influence ofaffluence in the choice of Assisted Reproductive
Technologies.
Methodology
The present study was started in March 2017 after
obtaining approval from the Institutional Ethics
Committee of Government Medical College,
Thiruvananthapuram, India, vide approval No.
06/06/2016/MCT dt.17/11/2016. A total of 202
males with azoospermia were selected from thesemen analysis registry of SATH for a period fromJanuary 2015 to December 2017 (Table 1).
Out of the selected cases, 164 patients were
included in the study (81%). Others could not be
contacted with the given telephone number and/or
address. After contact, the participants were met
personally during their visits at SATH. The couples
were informed about the study and consent toparticipate was taken. Non-structured interview
method was adopted for collecting demographic
data from each patient. The principal investigatordetailed the ethical, financial and scientific basis of
the study to each participant. Case sheets were alsoutilized to acquire patient history and demographic
data. The collected data were compiled andanalyzed. During the face to face interaction withthe couples, we came across certain ethical issues
related to economic status of patients and choice of
ARTs.
Table 1: Year wise azoospermia cases
Year
2015
2016
2017
Totak

Total Azoospermia cases
82
51
69
202

Findings

Figure1:
Various
Assisted
Reproductive
Technologies (GIFT: Gamete Intrafallopian Transfer, ICSI:Intra Cytoplasmic Sperm Injection, IUI: Intra Uterine
Insemination, IVF: In vitro Fertilization, OI: Ovarian Induction,
PGD: Pre-implantation Genetic Diagnosis, ZIFT: Zygote
Intrafallopian Transfer.)

During an ongoing research project funded by
the Department Health Research, Ministry of Healthand Family Welfare, Government of India, New
Delhi on azoospermia and pattern of Y chromosome
microdeletion in infertile males of Kerala in Sree
Avittom Thirunal Hospital (SATH), Government
Medical College, Thiruvananthapuram, India it wasnoted that the economic status of couples was a

Analysis of data revealed that the majority of thepatients approaching for ARTs at SATH were
economically weak. 75% of the participants had amonthly income of less than 1,000 rupees (USD 15)
per month and were unskilled/skilled laborors(Figures 2, 3).

Figure 2: Average monthly income of the study
participants

144

Eubios Journal of Asian and International Bioethics 29 (July 2019)

Figure 3: Job status of the study participants(Govt- Government, Pvt-Private)

Most of the study subjects completed basic
education (Figure 4) and had knowledge about thetreatment methods, its success rate anduncertainties of ARTs. During the direct interview it
was noticed that financial status and education
have a bearing on pursuing infertility treatment, thechoice of its selection and attitude towards
treatment. The high cost as well as the uncertainties
of ARTs together put more stress on patientschoosing the costly treatment options.
The patient case records showed that all theparticipants completed initial investigations likeblood tests, hormone analysis and scanning. But
solvency was a limiting factor when moving foradvanced treatment options like IVF, ICSI etc.
Presently, in India no private or public insurance
and/ or other agencies provides financial support
for male /female infertility treatment. Hence thecost of ART has turned into a limiting factor. The
majority of participants suggested an urgent needof policy change by the government to support theless fortunate.

Figure 4: Educational status of the study participants

Discussion

ARTs are well established treatments for many
types of sub-fertility, thus representing aconsiderable economic and healthcare implication
for patients, healthcare providers and society as awhole. The financial support and guidelines of ART
treatment share few common characteristics
among countries, ranging from generous, relatively
unrestricted public funding in Australia tonegligible public funding in US and most developing
countries (Mark et al, 2010). The Center for Disease
Control and Prevention (CDC) defined infertility asa “public health priority” similar to food safety,
heart disease and stroke (CDC, 2010). Householdincome can be considered as a strong predictor of
the choice of infertility treatments. Several reports
indicated a correlation between low socioeconomic
status and higher rates of infertility (Greil et al,2010). The economically marginalized groups havea lower opportunity to utilize advanced treatment
methods and for a majority, financial status will bea dead end for their dream to become a parent.
In the present study we observed that the
majority of the patients registered for infertility
treatment at SAT Hospital had high school level
education and were unskilled laborors. Educational
status is a determining factor related to infertility
and ART treatment. Previous data showed that therate of infertility is higher in patients with low
education (Fane et al, 2017). This may be becauseof a lower socioeconomic status along with low
education levels. Populations with higher
educational attainment often have higher income
and may choose options of treatment fromadvanced hospitals/laboratories. In order toaccomplish reproductive justice, these obstacles
must be surmounted.
We found that some of the patients discontinued
treatment once the preliminary investigations were
initiated. About 56% of the couples with infertility
seek medical assistance (Boivin et al, 2007). The
chances of success can be as high as 72% forcouples undergoing treatment as compared tountreated. But many choose to discontinue
treatment before attaining success. Discontinuation
is a primary determinant of the effectiveness oftreatment because it attenuates optimum clinicalbenefit. Inability to bear the costs of treatment is
one of the prominent factors responsible for the
discontinuation of infertility treatment (Gameiro etal, 2012).
Unlike other developing and developed countries,
the cost of infertility treatment in India is less. But
parallel to many other countries, in India also thefinancial burden of ART is not covered under any
public or private insurance companies. In thepresent study we observed that the majority ofpatients attending SATH were from financiallylower class. For the majority the initial laboratory
tests were feasible but the burden came intoEubios Journal of Asian and International Bioethics 29 (July 2019)
picture when they were sent for advanced
treatment options.
Our investigation infers previous findings ofother researchers that socioeconomic andeducational status have a profound impact on the
choice of ARTs and subsequently the chance to havea child (James et al, 2012). The government has totake necessary measures to support/subsidize thefinancial burden of the patients. In August 2018 theInsurance Regulatory and Development Authority
of India (IRDAI) removed infertility treatment fromthe list of “optional cover”, and made it part of“Standard Insurance Policies” thereby making it
more affordable to millions of infertile couples.
Moreover, if we make our own consumables underthe “Make in India” program, instead of importing
all of them which increase the cost of treatment, wemay be able provide ARTs much more affordable
than it is today.
The existing policies in different countries facesome common issues that need to be addressed by
the policy makers and insurers while planning for apolicy change. The most significant dilemmas
associated with infertility treatment are intricate
medical, economic, gender and ethical uncertainties
related to the cause, duration, cost and result oftreatment and this should also be considered. But
unlike other health issues the infertility and its
socioeconomic elements are less studied andaddressed by healthcare providers and policy
makers of our country. Further detailed scientificunderstanding related to the rate of patients’participation, treatment success and dropout
incidence in our population are needed.

Conclusion

The study concludes that the economic status of
couples influences the decision-making process ofchoosing ARTs. Since no financial support isavailable for ARTs in India, the government has totake necessary initiatives for policy change to help
the less fortunate and ensure that money should
not be a limiting factor for those who wish to
become parents of a child.
In addition,
policymakers should consider providing equalcoverage for male and female infertility care in
future health insurance laws.
Acknowledgment
This project was financially supported by the
Department of Health Research, Government ofIndia through Multi Disciplinary Research Unit atGovernment Medical College, Thiruvananthapuram.

References
Boivin, J., Bunting, L., Collins, J.A., Nygren, K.G. (2007).
International estimates of infertility prevalence andtreatment-seeking: potential need and demand for

145

infertility medical care. Human Reproduction.
22(6):1506-12.
Centers for Disease Control and Prevention. (2010).
Outline of the National Action Plan on the Prevention,
Detection, and Management of Infertility.
European Society of Human Reproduction andEmbryology (2016). "ART fact sheet".
Fane, G., Daniela, I., Man, Y. L., Raü l, S.L. (2017).
Educational Disparities in the Battle Against
Infertility: Evidence from IVF Success. EUI Working
papers. ECO 2017/05.
Gameiro, S., Boivin, J., Peronace, L., Verhaak, C.M. (2012).
Why do patients discontinue fertility treatment? A
systematic review of reasons and predictors of
discontinuation in fertility treatment. Human
Reproduction Update. 18: 652–669.
Greil, A.L., Slauson-Blevins, K.S., McQuillan, J. (2010). The
experience of infertility: A review of recent literature.
Sociology of Health and Illness. 32, 140–162.
James, F., Smith, M.D., Michael, L., Eisenberg, M.D., David,G., Susan, G., Millstein, Marcelle, C., Thomas, J., Walsh,
Jonathan, S., Lauri, A., Pasch, Nancy, A., and Patricia, P.,
Katz. (2012) Socioeconomic Disparities in the
Utilization and Success of Fertility Treatments:
Analysis of Data from a Prospective Cohort in the
United States. Fertility and Sterility. 96(1): 95–101.
Mark, P., Connolly, S.H., Georgina, M.C. (2010). The costand consequences of assisted reproductive
technology: an economic perspective. Human
Reproduction Update. 16: 06:603-613.
Sharlip, I.D., Jarow, J., Belker, A.M., Lishultuz, L.I., Sigman,
M., Thomas, A.J., Schlegel, P.N., Howards, S.S., Nehra,
A., Damewood, M.D., Overstreet, J.W., Sadovsky, R.
(2002). Best practice policies for male factor
infertility. Fertility Sterility. 77: 873-882.
WHO 2013, available at:https://www.who.int/
reproductivehealth/topics/infertility/definitions/en/

Living the anthropocene from ‘theend of nature’ to ethical prospects- Jan Gresil S. Kahambing
Leyte Normal University, Tacloban City, Philippines
Email: vince_jb7@hotmail.com

Abstract
This article explores the viability of life after ‘theend of nature’ – as Zv iž ek reports – in the
Anthropocene. Humans can no longer consistently
rely on their persistent interventions to nature as
its source. The end of nature, however, does not
only mean that the problem is solely ecological.
Instead, it points to the original chaos ofcatastrophes that disturb the link of man’s
relationship to nature. In short, the current
predicament of the times not only exposes
problems of ecology per se but also of economy,
biology, and society. So, what comes next? Taking
off from Heidegger and Leibniz, ethical prospects

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Eubios Journal of Asian and International Bioethics 29 (July 2019)

after this four-fold end should reopen the task ofthinking the Anthropocene in various independent
but coalescing fronts.
From ‘the end of nature’ (disturbance)…
In 2010, Slavoj Zv iž ek enumerated four catastrophic
events summing up his report of the end times as
the ‘four horsemen of the apocalypse’ in allusion to
the last book of the Bible, Revelation (Greek:ἀποκάλυψις; apokálypsis). Zv iž ek discusses in Living
in End Times (2010a) the four horsemen:
Impending ecological catastrophes (as ecology), theglobal financial meltdown (as economy), thebiogenetic revolution and its impact on humanidentity (as biology), and the social divisions
leading to the explosion of protests and revolutions
worldwide (as society). Is it not precisely the
popularity
oftheacademic
buzzword‘Anthropocene’ – man (anthropos- ‘ἄνθρωπος’) +new (-cene ‘καινός’) – already an indication of how
the current geological epoch is heavily influenced
by man’s constant intervention, especially the sideeffect of technological innovations leading to plant
and animal mass extinctions, ocean pollution,
atmospheric alterations (Stromberg, 2013), andloss of biodiversity (cf. Pope Francis’ Laudato Si’,
Zimmerer et. al., 2019)? Zv iž ek (2015) delves further
into the current crisis and raises the task ofthinking the Anthropocene, first by exposing that it
disrupts the sustainability of nature and second bygoing into the extreme that ‘Mother Nature nolonger exists’ – that it is already unstable (she is, in
his words, a ‘crazy bitch’: see Zv iž ek 2010b) – using
McKenzie Wark’s Molecular Red: Theory for the
Anthropocene:
1.
The Anthropocene is a series of metabolic
rifts, where one molecule after another is extracted
by labor and technique to make things for humans,
but the waste products don’t return so that thecycle can renew itself (Wark, 2015, p. xiv)
2. We still tend to think that if we stop certain
actions, the ecology will right itself and return tohomeostasis. But perhaps that is not the case…
What if there is only an unstable nature. (Wark, p.
200 as cited from Zv iž ek, 2015)
In what other case can one make sense out of
this? The failure of the modern project allows forthe understanding that any sort of metaphysics ofnature can no longer work, following from
Schelling’s report (Schindler, 2007). Science andreligion in this sense may have overtaken aphilosophy of nature but these two as
representatives of man’s enlightenment project
failed in keeping at bay the supposed homeostasis –the by-product prospect of modernity’s reification
methods to control nature (cf. Minteer, 2012).
Nature becomes disturbed when the fundamental
link that tries to objectify nature as its specimen iscut off. What is ‘nature’ in this regard? Nature is ‘tobe understood here in the traditional sense of aregular rhythm of seasons, the reliable backgroundof human history, something on which we cancount on to always be there (Zv iž ek, 2017b).’ In thissense, the life that is overviewed as a context ofhuman intervention is one that is a ‘constant
struggle against apparently unpredictable elements(Zv iž ek, 2017b).’ And this signifies a paradox in the
Anthropocene: ‘humanity became aware of its selflimitation as a species precisely when it became sostrong that it influenced the balance of all life onearth (Zv iž ek, 2015).’Zv iž ek (2017a, 2017b) then caps ecologicaldisturbance, particularly when hurricane Irma
occurred, as an affirmation of the ‘end of nature’.
The implication would be that nature in its end
would no longer serve its purpose in the
Anthropocene:“When we can no longer depend on it[nature], we enter what we call “anthropocene”:
a new epoch in the life of our planet in which we,humans, can no longer trust the Earth as areservoir willing to absorb the consequences ofour productive activity.”This period being that ‘humans have noticeably
impacted the patterns of geological erosion andatmospheric chemistry’ (Crutzen and Stoermer ascited by Waller, 2019). Nature – the m(other) thatfigures the balance of things – in this sense, dies.
Moreover, the prospect of this end is reflective of aconsequentialist follow-up of God’s death, aNietzschean killing of a feminine other: “after thedeath of the God-Father, the masculine reason, we
should also endorse the death of the GoddessNature” (Zv iž ek, 2015). But there is no balance thatcan withstand the destructive force that alreadycharacterizes the figure of nature at the moment.
The end of nature signifies the breaking away fromtraditionalist conceptions of modern progress andeven the sustaining pantheistic essentialism that
underlies it. As Wark puts it:“the God who still hid in the worldview of an
ecology that was self-correcting, self-balancing
and self-healing—is dead … The human is nolonger that figure in the foreground which
pursues its self-interest against the backgroundof a wholistic, organicist cycle that the humanmight perturb but with which it can remain inbalance and harmony, in the end, by simply
withdrawing from certain excesses.” (Wark,
2015, p. xii)
How does one consider this ‘end’? The idea isthat all the four horsemen cannot be taken
individually: all four are crucially connected that in
the end man bears the destruction altogether.
Asserts Zv iž ek (2010a):Eubios Journal of Asian and International Bioethics 29 (July 2019)“the common-sense reasoning which tells us
that, independently of our class position or of
our political orientation, we all will have totackle the ecological crisis if we are to survive, isdeeply misleading: the key to the ecologicalcrisis does not reside in ecology as such.” (pp.
333-334).
Alongside ecology, the complex interweaving ofsocietal, economical, and biological concerns also
affect life in the Anthropocene. In the case of
biology – the common denominator of technology
inserting itself into the fabric of human society –organizations, for instance, captivate studies that
center the terminology on the posthuman such as a
‘Posthumanized Future Workplace’ (Gladden,2018) where there is a posthumanizing process in
the growing number of adoptions of ‘social robotics,
advanced AI, virtual reality, neurocybernetics, andubiquitous computing.’ And this virulent intrusionof bioengineering has consequences not only to thesociety and economy, but also to ecologicalresources for sustenance.
If there is a crucial lesson of confronting thisecological disturbance, it is that the ethicalprospects to address this would have to be inmultifaceted fronts, which means that they would
have to be independently orchestrated. What thisfurther means is a concoction of Heideggerian andLeibnizian train of thought. Heidegger’s ‘end of
metaphysics’ is often a look at the manifestation of
his criticism against the onto-theological traditionof scholasticism, the critique of the remaining
Nietzschean ‘metaphysical’ pronouncements, and atransition to nihilistic times (cf. Heidegger, 1973).
But isn’t it also telling of the fact that since this endofphilosophy
debunks
theunderlying
presuppositions of essentialist precedence, this‘end’ also means a further independence of thesciences and their various tractions to thinking,namely, the opening (or unveiling) of thought?
Anent to this, Leibniz’s Monadology (cf. Rescher,2014) comes to mind as a juxtaposition to the
independent courses of thought. The Leibnizianview of this world as ‘the best of all possible’ ones,
allows for sufficient reason to suppose that theharmony of things is not found in an explicit
manner of connection (man and nature, in thiscase), but of a bigger picture of synchronization
upon seeing the independent courses of events.
Which is to say that, like an orchestra, theindependent musical pieces of various instruments
would coalesce in the end towards a grander
melody. In these tasks, one might see an opening
for fitting diagnoses.
(Orchestrating) Ethical Prospects
There is, then, a viability to seek ethicalconsiderations as interventions. And these had to147

crucially consider, aside from ecology, the otheraspects of economics, society, and biology as well. It
is to be noted, moreover, that the challenges thatare posed in finding perspectives for ethics must be
framed in the question of responsibility and must
elicit ‘an ethics that comes from being human,required to bring about sustainable features’ (cf.
Chin et.al, 2017). Will our ethical response beframed within that of responsibility or some otherperspective? What are other ways of seeing thingsvis-à-vis the responsibility of nature and ethics
altogether?
Converging ideas to propose concrete solutions
are perhaps fundamental in this case. Siegle (2016)
in the ethical guide to the Anthropocene suggests acurtailing of negative trends by thinking differently.
Under processes of climate change, humans must‘transition away from a fossil-fuel world economy
in the next 25-30 years.’ She takes the proposal of
the UN’s Global Climate Change Summit in
Marrakech: from four outdoor gym machines thatgenerate electricity while exercising to fashion
ideas turned into production through ethical means.
It is significant in this regard that a responsible
agency within the epoch is connected to some formof character reshaping. On the religious side, Pope(2018) proposes a cruciform ethics which is bornout of the kenotic ethic of Christianity. This positionentails, via population, a ‘self-emptying of ourendless desires to reproduce ourselves’ to address
the large carbon footprint of the planet. It alsomeans less consumption in human societies definedby a gluttony of ‘excessive or wasteful eating, or
energy profligacy.’ This follows from what he calls
Sabbath economics, where the earth consumption
must rest every seven years. A specific route that it
takes is vegetarianism, which lessens the treatmentof ‘animals as commodities and not creatures.’ Italso prevents the high consumption of animal
proteins that enables methane emissions and theglobal collapse of fisheries. Vegetarianism in thissense reduces greenhouse gas emissions and thefuture impacts of climate change (Pope, 2018).
Under this proposal, one becomes responsible forcurtailing one’s desires.
Taking the necessary cue of asking the reason
behind the sudden crisis of Anthropocene despite
preceding decades of environmental ethics, Paul(2018) takes a different theorizing onunderstanding the responsible relationshipbetween human and the environment. There is asense in which the urgency of the environmental
ethics in the Anthropocene is no longer a matter ofmoral debate but already a ‘question of the very
survival of life on Earth, including ourselves (p.
2896).’ She contextualizes, following from Latour’sargument of the ‘paradox of modernity,’ that there
is a ‘hyperseparation between nature and society’148

Eubios Journal of Asian and International Bioethics 29 (July 2019)

and this is processed either through purification (isthe phenomenon purely natural or social?) or
through translation (the environment is a socialand political construct). Paul thinks that there
should be a ‘hybridize notion of environment’against the purification process. Like Zv iž ek, Paulhighlights the realization that environmental
problems are ‘neither in human nor in nature,
rather it lies in the relationship’: in the height of the
Anthropocene era, ‘the environment we encounteris no longer “natural,” and we as humans are nolonger just cultural or social.’ So there is a need fora phenomenological perspective in analyzing thesituation, which is to say that one must view thesituation as an experiential knowledge of theinterconnectivity of humans and nature. Both mustbe given equal priority.
Following from a phenomenological standpoint,
Zylinska’s Minimal Ethics sees the Anthropocene ‘asa phenomenon and a discourse’ that elicits anethical response coupled with human responsibility.
Humans can no longer be regarded as theaggrandized figure to take care of the earth. Instead
one must tone down this hubris into what she callsa ‘narrative of humility’ or a ‘minimal narrative.’
This is reminiscent of the Lyotard’s report ofdispelling grand narratives (cf. Lyotard, 1984) as
well as Jenning’s proposal of cultivating humility incivic governances that are centers of decisionmaking (2016). In this sense, the need for betterstories is part of a phenomenological lens. For
Zylinska, a ‘better story would be a story thatmakes such power distinctions visible. Otherwise
there is a danger of the Anthropocene becoming
this kind of great leveller in which everyone isequally guilty (Valero, 2018; Zylinska, 2014, p. 46).’
A non-normative story would have been a narrativeof responsibility without rushing towards solutions.
Another possibility is revealed from those whoslightly distance with the emerging analysis of analready-framed picture of responsibility that seems
to take on a conservative ‘social justice’ kind oflooking at things. The manner of argumentation
proceeds from a revisiting or rethinking of thought
while not bringing out a purely retroactive solution.
Hamilton et. al (2015) think of the banality in termsof ethically addressing the situation. Moving awayfrom Paul (2018), they point out that the task isdeeper than a call for interdisciplinarity around‘hybrid “socio-logical” objects’, so the era of humansocial contracts must be “rethought.” Pacing inrationalization, one of the crucial points of noteasily succumbing to the parade of proposals is theso-called “political Anthropocene” forwarded by
Karera (2019) who notes that the new managementof Anthropocene ethics is ‘unequipped to face the
racial histories of our current ecologicalpredicament’ and should not neglect ‘black

suffering.’ It is then important to highlight thesignificance of political consequences in any ethicalvariants. Without taking amiss the racial
antagonisms of society at large, current proposals
must be fortified with critical potentiality. They
must be ready to face the era head-on sans denying
the ‘geological impact of human force on nature’ or
uncritically assessing the promotion of capitalist
values while compromising, through disavowal,social antagonisms.
With the common dismissal of modern ethicaltraditions predominating the discourse of the
Anthropocene, Schmidt, et. al. (2016) suggest areassessment and repositioning of traditional
issues as well as identifying novel ethical problems.
Trachtenberg (2017) agrees with it whileemphasizing on the richness of traditional ethicalconceptions and marking the important method of
rereading. There are important approaches thatmust be revisited. For instance, with the ‘large-scale
uncertainties and struggles to address collective
action problems,’ one can hinge on a virtue ethics
that molds justice, truthfulness, and hope incharacter development (cf. Jamieson, 2014;
Williston, 2015).
One should also not easily terminate those whoare affected by the complexity of moving beyond
nature or ultimately proceeding to an automatedresponse of accepting the current constellation of
events. Here, one can think of Rolston (2017) who
proposes entering not the Anthropocene per se, but
a Semi-Anthropocene, a modestly wiser and more
ethical course, which is not to go beyond nature andkeep the ‘natural symbiosis’ with humans. Thisview is consistent with the paradoxical thought
forwarded by Jacques Lacan who says: ‘I don’tmuch like hearing that we have gone beyond Hegel,the way one hears we have gone beyond Descartes.
We go beyond everything and always end up in thesame place (Lacan, 1990, p. 71).’ Such is true for themost part when it comes to the nomenclature foundin the academia where one simply coins a different
name for a somewhat analogous concept. Many
names can be called for the dimensions of looking
at the new changes in the period, but one canreduce them to a main thematic condition. In one of
Chan’s (2019) six urban conditions ethicallyexamined in the Anthropocene, for instance, two of
which is simply precarity and fear. But one should
never take these two lightly as they are patterns ofthought that are analogous to other sophisticatedformulations as well.
In a somewhat different coinage, therefore, Miles
and Craddock (2018) propose a “Biome Ethics” (aspreferable to Anthropocene ethics), which isdifferent
frombioethics,
eco-ethics,
andenvironmental ethics. This is to be understood as a
global biome rather than a parochial one because itEubios Journal of Asian and International Bioethics 29 (July 2019)
comprehensively captures relationships ‘between
human activity, all life forms, and the environment.’
They consider the non-neutrality of Anthropocene
by calling out the ‘particular histories ofcolonization and capitalism’ which are responsiblefor ‘various mechanisms of oppression, exploitation,and displacement.’ Considering the larger context
then, the principles and values for Biome Ethics areconnectivity, human and nonhuman continuum,
and shared suffering. The idea is that consumption
is based on an environment of global connections,from production to human and nonhuman relations,so that the suffering of one redounds to thesuffering on the other – a kind of shared suffering
which Donna Haraway bases from the feeling of
empathy rather than cognition. With the prospectof the end of nature, Biome ethics refocuses on theinterconnectedness for life forms. And this evendisavows an ethics of responsibility because of theimperative nature of obligation contracts, rights,
and enforcement rather than what is to be desired.
Clearly, these proposals are ironicallyindependent while promoting interconnectedness,
responsibility, and so on. However, what if these
ethical prospects in their own ways can in the end
not only pursue the discourse of Anthropocene
ethics or whatever name one has for it to explain
the current epoch: what if with some paradoxical
twists and turns of events, a wide tapestry ofconsequences will also lead into a resolved future?
Going steady with concrete proposals of energy
conservation, calling on for interdisciplinarity,
rereading or rethinking previous ethical traditions,developing character-based movements on
humility, hope, empathy, justice – these are not
short-term prospects with immediately seen effects.
It would be a trap for visions to quickly demand
automated solutions to living in the Anthropocene.
Instead, one might just well pursue independent
courses of actions for an orchestrating by-productin the end. Or to quote Zv iž ek’s Living in the End
Times (2010a, p. 182), which pursues a thought that
does not rely on a carefully linked and fast-paced
protocol of solutions: “one does not wait for the"ripe" objective circumstances to make a revolution,
circumstances become "ripe" through the politicalstruggle itself.”

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global politics. The Independent. Retrieved fromhttps://www.independent.co.uk/voices/hurricaneirma-climate-change-recycling-donald-trumprehousing-slavoj-zizekZylinska, J. (2014). Minimal Ethics for the Anthropocene.
Open Humanities Press.

Book Review of Beyond Bioethics:
Towards A New Biopolitics

By: Obasogie, O.K. and Darnovsky, M. 2018.
University of California Press. 518 pp.
ISBN 978-0-520-27784-7
by Alex Waller, Ph.D.
Khao Yai International School, UK/Thailand; AUSN
Visiting Professor of Science Education andEnvironmental Ethics
Email: arwaller1@hotmail.com
Bioethics plays an increasingly important role
debates regarding and the pathways followed inscience, medicine and innovative technologies. It isa widening field that encompasses considerations
frompatient,
medicalpractitioner,
environmentalist, sociologist, legal, economic,
religious, philosophical and scientific perspectives.
Bioethics can incorporate ethical dilemmas that

relate to all biota such as the broader Britannica
definition or to the narrower Merriam Webster
dictionary definition that refers to biologicalresearch and especially that involving medicine. In
this book Beyond Bioethics the essays are written byexperts within the latter field, largely focusing on
reproductive technologies and genetic engineering
issues related to the provision of health care.
Nonetheless key insights that are pertinent to all
bioethics are illustrated throughout the text, suchas a perceived shift from the primacy given toadherence to the precautionary principle towards
greater decision making based foremost on
principles of consumer entitlement.
This collection, of over fifty essays, is divided intoten parts. The first two present some historicalbackground and critique of bioethics including
eugenics, principlism, feminist and disability rights
issues. Subsequent sections delve into arguments
surrounding emergent technologies and thegrowing influence of consumer market forces in
dictating medical provision. There is a section that
addresses the research ethics of medical testing. A
number of essays tackle debates over fertility
clinics, designer babies and race-based medicine.
The final section looks to the future; one argues formore democratic citizen engagement in decision
making over the use of CRSIPR technology rather
than a moratorium based on assessments made by“experts”. Do the rights of wealthy individuals indeveloped countries to have “perfect” babies
infringe on the principles of human dignity,
protecting future generations, the biosphere andbiodiversity as called for by the UDBHR? Indeed,
one of the failures, in my opinion, of thiscompendium is the general lack of reference to
UDBHR. The guidelines of which have strengthened
political arguments, supported the development ofbioethics committees and helped design legal
frameworks in many nations, especially those of the
global south. The absence references to this widely
recognised soft biolaw surely reflects the blinkered
view of the rest of the world’s political processes by
the editors.
My further concern is the limitation of presenting
bioethics as merely the field of biomedical ethicalissues dealing with personal values, rights andresponsibilities. These are all well and good, butthey promote health and wellbeing for individuals
before consideration of wider communities orpopulations let alone other living organisms andour interdependence with them. The obsession for
the right of every person to have their own
offspring, at this point in time with exponential
human
population
growthandrisingenvironmental problems, runs counter-current tomorality based on virtues such as moderation,

Eubios Journal of Asian and International Bioethics 29 (July 2019)prudence, justice or self-discipline. If values andmoral decisions are framed in narrow medical
ethics terms, or if these override environmental
ethical considerations without first and foremostand remaining continually aware of ourinterdependence on other species and our natural
world, then in the long run we are heading down adead-end alley.
We can be given a glimmer of hope thatbioethical medical issues have inspired some shifts
in political action and processes such as the 1975
Asilomar agreement regarding recombinant DNA
technologies. Let’s hope the second edition of thetext sees the necessity and wisdom ofencompassing bioethics beyond the humanfishbowl, recognizes what has already beenachieved in some less developed countries andcelebrates the potential and influence ofinternational agreements such as the UDBHR.
For forthcoming conferences see: www.eubios.info
Email to Darryl@eubios.info.

Legacies of Love, Peace and Hope: How
Education can overcome Hatred and Divide.
https://www.eubios.info/legacies_of_love_peace_and_hope

We welcome persons and collaborators tocontribute papers, and also to join a launch
conference of this book in Christchurch at some day
between 25-29 September 2019.
Email: darryl@eubios.info

Twentieth Asian Bioethics
Conference (ABC20),
Dhaka, Bangladesh, 22-25 November 2019.
http://abc20.bioethics.org.bd/index.html
Organisers: Asian Bioethics Association,
Bangladesh Bioethics Society, Eubios Ethics
Institute, AUSN, and others. Contact: Prof. Shamima
Lasker, Email: splasker04@yahoo.com
EJAIB Editor:
Darryl Macer (Chair, Accredited Universities of Sovereign
Nations)
Associate Editor:
Nader Ghotbi (Ritsumeikan Asia Pacific University, APU))
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),

151

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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Eubios Ethics Institute Publications (Books sent by SAL post, Journal by Airmail - Price included)
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Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture
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Equitable Patent Protection in the Developing World
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Attitudes to Genetic Engineering: Japanese and International Comparisons (Bilingual)by Darryl Macer, May 1992 330pp.
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Bioethics for the People by the People by Darryl Macer,... May 1994 ISBN 0-908897-05-7, 460pp.
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Bioethics in High Schools in Australia, Japan and New Zealand, by D.Macer, Y.Asada,
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Bioethics is Love of Life: An alternative textbook by Darryl Macer, July 1998 ISBN 0-908897-13-8,
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October 1999 ISBN 0-908897-14-6 (Japanese), 320pp.
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Ethical Challenges as we approach the end of the Human Genome Project
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Bioethics Education in Japanese High Schools (in Japanese only)
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Bioethics and the Impact of Human Genome Research in the 21st Century
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Bioethics in Asia in the 21st Century
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Challenges for Bioethics from Asia Ed: Darryl R.J. Macer
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Bioethics in Iran, Editor: Alireza Bagheri, 2014. ISBN 978-0-908897-25-4 262 pp.
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Bioscience Ethics Education Curriculum for Pre-Schoolers to Elementary Age Children,
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Getting Along: The Wild, Wacky World of Human Relationship, Laura R. Ramnarace 2017
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Diabetes: A Reader, Rajib Biswas, 978-0-908897-30-8 (A4) 2017
Education, Happiness, Mindfulness and Colonization: Reflections from Time with San Carlos
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Philosophy and Practice of Bioethics across and between Cultures, Takahashi, Takao; Ghotbi,
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