Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 26 (3) May 2016www.eubios.info ISSN 1173-2571
Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2016 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contentspage
89

Editorial: What is Dignity?
- Darryl Macer
Cross Cultural Perspectives on Dignity, Bioethics,
and Human Rights
90- María Isabel Cornejo-Plaza & Darryl R.J. Macer
Developing a Context-Sensitive Patient-Physician
Relationship Model for Health Care in Bangladesh 95- Md. Munir Hossain Talukder
Violence and terrorism in the Middle East101
- Nader Ghotbi
Hospital food Manipulator’s Moral Judgment
Evaluation of Hand Wash Technique Training
106- QCB Marcela Mas-Treviño, Dr. Pedro César
Cantú-Martínez, MSP César Eduardo Luna-Gurrola
Student Perceptions and Attitude towards Bioethics
Teaching to Undergraduate Medical Students
112- Zoheb Rafique
Perception of Nursing Ethics among Undergraduate
Nursing Students at a Nursing Institute of Pakistan 115- Zoheb Rafique
Prospects and Problems of Stem Cell Research in
Bangladesh: Can Equity and Justice be Maintained in
the Context of Public Health Demand?
117- Abu Sadat Mohammad Nurunnabi
Medical Experimentation, Ethics and Regulation:
Some Strands of Enquiry
125- Ankita Chakravarty
ABA Renewal and EJAIB Subscription
128
Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
Provost, American University of Sovereign Nations(AUSN), Arizona, USA
Email: darryl@eubios.info
http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: What is Dignity?
This issue includes 8 papers that could be grouped
as commentaries on different aspects of promotion of
dignity, as an essence of bioethics. As the first article
by Isabel and myself explores there are many
embedded meanings in the term “dignity” which is
widely used in international law and ethics. Promotionof a good-life (Eubios) for all beings will necessitate
protection of their dignity.
There are several applications of this term in thepapers on patient-physician relationships, the paper on
hand-washing by food industry workers, and the paperon linkages between violence and terrorism. In all thesecases abuses of dignity are clear to see upon analysis,but often bad habits and group mentality leads topeople forgetting the dignity of others.
Two papers on bioethics education in Pakistan
explore how students can be taught about bioethics,
and how to protect dignity of patients. The abuse ofdignity also reduces the dignity of the abuser. The final
two papers look at medical experimentation and stem
cell research, and the abuses that often have occurredin developing countries.
EJAIB announces that the September 2016 issue
will be a special issue with contributions submitted
for the first World Bioethics Day, which will becelebrated on 19 October 2016. Please submit
articles accordingly.
The Asian Bioethics Association (ABA) and local
hosts, UGM in Jogyakarta, Indonesia, have released
the Call for Papers for ABC17 to be held 14-17
November 2016. Readers are also invited to see theforthcoming conferences page to find satellite meetingsin Malaysia, 9-11 Nov, and in Kumamoto, Japan, 19-21
Nov 2016. AUSN and Eubios Ethics Institute are alsoco-organizing with others a number of Bioethics
Conferences trainings in 2016 all around the world, so
please join.
- Darryl Macer

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

Cross Cultural Perspectives
on Dignity, Bioethics, andHuman Rights- María Isabel Cornejo-Plaza, L.L.M.
Professor of Bioethics and Law, University of Chile andUniversity Diego Portales. Law School. Studying for a
Doctorate in Law at University of Chile and Master of
Bioethics and Global Public Health, American University ofSovereign Nations (AUSN), Arizona USA.
Address: Av. Santa María 0200 Providencia, Santiago, Chile.
Email: isabelcornejo@u.uchile.cl- Darryl R.J. Macer, Ph.D.
President, American University of Sovereign Nations (AUSN),
Arizona USA.
Email: provost@ausn.info

Abstract: The concept of dignity is the foundation of
fundamental
rightsexpressedininternational
declarations on human rights and bioethics. Sometimes
there are collisions of rights, which must be weighed.
However, more often dignity is invoked in order toargue for or against the same issue. Is it possible that aconcept can be so broad that it becomes meaningless?
What do we mean when we argue for moral decisions
based on dignity? This paper aims at understanding
dignity as a construct, in an analytical and evolutionary
cross-cultural approach, from a Western and Easternview, and then considers its impact on the teaching of
human rights and biolaw.
Key words: Dignity, Bioethics, Human Rights, Biolaw,
Self-Determination, Freedom
Introduction
This paper aims at positioning the idea of dignity inthe context of human rights and bioethics from anintercultural perspective. Both discourse in the fields ofhuman rights and bioethics have invoked the word
dignity as an argument in reflections involving thedefense of personal welfare, of community identity, andhumankind in general.
Dignity is a construct, a spiritual imperative toshape a vague sense of the uniqueness of the humanbeing. It is often used to argue for a universality ofcultures in a multicultural, interconnected and global
society. The expression that some action is an affront
to dignity is often agreed between persons from various
cultures, with some clear examples defined ininternational law such as genocide. Some other issues
however see arguments between persons, andPeoples, on what is a dignified approach, such as indiscussions of death with dignity and the end of life.
The paradox is that the very origin of the word
indicates that there may be different levels of discursive
use. Thus, "Dignitas" in the sense of a special
qualification for "power" or "authority", is notcomparable to "inherent dignity" as a feature ofhumanness. Only after the Enlightenment did it cometo be considered as a quality of all human beings.

Recognizing the core of the fundamental dignity inrationality in Kant, Pico della Mirandola, Dworkin,
McIntyre, Gewirth, Nino and others assigned value tohuman beings by virtue of their rationality. However, thefoundation of dignity in reason could not be anadequate explanation to maintain the life a person in avegetative state for 41 years, or to understand thedisability or special abilities in the sense currently
accepted by the doctrine of human rights.
Background of the idea of Western dignity
The evolution of the concept of dignity moves fromthe ancient Greek and Roman conceptions, different
from what we understand today, through therevolutionary conception of Christianity up to thesecular Kantian idea of dignity. Those have been
influential in our Western legal systems. In Greece theconcept of dignity is different from what we think today.
The closest idea to dignity in Greek culture is the ideaof honor (time) (Chuaqui, 2008). From an
etymimological point of view the word is akin to theconcepts derived from Axios (worthy), and more closer
to dignitas are: Axia and axiom in the sense of dignity,
value, prestige, although they are not comparable todignitas in content, brightness and frequency. In
relation to the prestige enjoyed by prominent politicians,
axiom appears regularly on Thucydides. Plato thinksthat axiom means value, prestige, and thus it appears
in the Republic. Also Demosthenes referred to the cityand the Greeks. In Greek philosophy the term axiom isused to refer to the place of the man in the cosmos andthe range of his spirit or soul. In the Stoics it comes tomean value (Chuaqui &Rodríguez, 2002). Before
Christianity, Gentiles, slaves, patricians and plebeians
had not only a different legal status, but not all wereconsidered humans. The slaves had the legal status ofa thing, so that its owner could exercise over them all
the attributes of ownership (Cornejo & Escorza, 2014).
Dignitas in Rome was related rather to the politicalsphere, providing rights and power to the owner.
Dignitas also had gradations, and would increase,decrease or be lost, having clear aristocratic features.
Cicero separated moral from political dignity. For Cicero
every man, to be recognized as such, will havesomething divine, godlike and dignity. The idea of
divine creation of man was in the mind of Cicero andOvid, but it may be considered only a hint that did not
develop into doctrine. However, Cicero advanced someelements of the modern concept of dignity. In Christianculture dignity is given by the relationship of the humancreature with God and the idea of divine image andnature.
This idea of equality among humankind, is central
to the Christian doctrine. Men and women are worthy ofGod's love, because their nature makes them worthy ofhis precious protective mantle. Men are equal between
them. Just God, is the example and perfect guide. Thisidea is absolutely new, revolutionary, not seen in theHellenic world.
There was the figure of the apatheia in Greece, inwhich a disciple hired a teacher, seeking release ofEubios Journal of Asian and International Bioethics 26 (May 2016)
pathos, the passions that take over and enslave thesoul. The subordination to a guide is seen as thevehicle to move from a state of disorientation to anotherstate, and become master of one´s own life. Such
direction was paid and temporary. But God, the pastor,
directs permanently. Such a conception continued todevelop during the Middle Ages. Renaissancehumanism, through Pico della Mirandola, begins to link
dignity to free will, freedom of choice and rationality.
The revolution of Christianity, according toFoucault, was founded on the idea of will. First, the willof God, vertically seeks salvation of the souls of thefaithful, through obedience to reach those who should
give eternal life to himself. This waiver concerns thepassions of human nature that is expressed as sin in
the Catholic doctrine (Foucault, 2006). Christianity inWestern culture crystallized its perennial influence in allareas of knowledge, as the Hellenic culture in antiquity;
Christianity did it in the Middle Ages and theRenaissance. Despite the skepticism related to Catholic
dogmas and their abuse in the name of faith, the ideaof equality had already settled in such a way that evenin the process of secularization ideas of equality wereincorporated in the Age of Enlightenment.
Rationalism, free market, prosperity of nations andthe end of the feudal order, were a cause and effect of
the Enlightenment, a process that spanned most of theeighteenth century. Its principles shaped the modern
constitutional state. The ideas of the French Revolution
and the Constitution of United States constituted
sources of inspiration and guidance for constitutions
and legal bodies in Latin America and influenced
legislations worldwide.

91

Dignity needs a context
Leaving aside the Platonic essentialism, andunderstanding language as a convention, it may be
futile from an analytical point of view to search for an
univocal concept of dignity. Trying to throw light on theconcept we can create a pseudo-problem if its’
meaning does not consider the context of its usage. As
Taylor notes, "the demand for individual rights
presupposes belonging to a specific community definedby specific traditions” (Taylor, 1985). Thus, instead ofasking what dignity means, we should ask what it isdignity for, who or who applies the notion, who protects,
what or why it is invoked, etc. ... Hobbes says: "Thenames of things that affect us, namely that we like anddislike are of variable significance in the constantspeeches of men ... " "therefore, the reason a man
should ponder the words; which, next to the meaning
we imagine by their nature, they also have their own
meaning of nature, willingness and interest of the
speaker” (Hobbes, 1978).

says that morality consists of rules that any rational
person can accept under ideal conditions (MacIntyre,1984). The Kantian proposal has been radical incontent to give dignity to the autonomy of man, when
he expresses: "the rational beings are called persons
because their nature distinguishes them as ends inthemselves, that is, as something that cannot be used
as medium and therefore limited real treat in that sense(Kant, 1988). "Identifying the human capacity for moral
choice with the existence of free will" (Mosterin, 2006).
In one of his last books, Justice for Hedgehogs,
Ronald Dworkin pointed out that respect for humandignity involved: respect yourself, take care of theconsequences of decisions made in serious andauthentic ways, that is, identify personal responsibility
for finding what is considered successful for life. These
two principles, respect yourself and authenticity, should
serve as a personal ethics in pursuit of the good life
(Dworkin, 2011). For Ruth Macklin, the issue of dignity
is subjective, difficult to live up to the powerful moral
claims that are assigned an ambiguous notion. In 2003
she said: "Bioethics has struggled really well with theprinciple of personal autonomy in the idea that all
human beings have the same minimum capacity to
suffer, prosper, reason and choose. No human being
has the right to interfere in life, body, or freedom ofothers ... once admitted the principle of autonomyargument Macklin, "dignity" not care” (Pinker, 2008).
For some authors human dignity and dignity ingeneral should be distinguished. Herbert Spiegelberg
says: "dignity in general ... is a term with many
meanings. It applies to humans and nonhumans, andmainly indicates certain distinctive qualities that give
more than others who have certain qualities range.
Indeed, dignity in general is a matter of degrees. This isreflected in a picture of reality in the traditional "Great
Chain of Being", with upper and lower dignities. Suchhonors are subject to change, can be acquired and lost,increase and decrease. This expression is found in
those dignities granted to certain people called
dignitaries, by their titles or honors, and can be
expressed in worthy or unworthy behavior. Humandignity is a very different matter. It implies a real
negation of grades or orders of dignities. It refers to aminimum of dignity for all humans as a species"(Spiegelberg, 1970).
Spiegelberg considered inherent dignity as a
subjective right of individuals. This word is used withsuch connotation for the first time in the Enlightenment
by John Locke. The Constitution of the United States
began contextualizing dignity as a range or signal
recognized in certain people within certain social
hierarchies. But later thinkers understood dignity as abroader concept applied mainly to human beings.

The dignity and distinction, existence and degree
requirements
Carlos Nino observed that the central nervous
system appears as condition sine qua non not to know
who the subjects of rights are, but to know who canenjoy the benefits they provide (Nino, 1984). MacIntyre

Pacific concepts of dignity
The concept of dignity is also seen in many PacificIsland cultures. The New Zealand Health ResearchCouncil Guidelines on Pacific Health Research (HRC,
2004), include the term “dignity” in a few sections. For
example in article 7.4 “Participants must be able to92

Eubios Journal of Asian and International Bioethics 26 (May 2016)

withdraw at any stage of the research process with
dignity, and respect, and without embedded
disadvantage.” The context of the term implies that inan ordinary sense they possess dignity, in a honorable
sense of the term. Interestingly however, unlike manyInternational Instruments, the term “dignity” is not listed
among the core values, which are: “They are centred
on relationships as the overarching principle that binds
each of the following ethical research principles:
Respect,
CulturalCompetency,
Meaningful
Engagement, Reciprocity, Utility, Rights, Balance andProtection. These have been identified as the guiding
principles for conducting ethical relationships forresearch. These values are a summary of many of thevalues found around the Pacific, and further examplesof values will be discussed when reviewing specificcases.” (HRC, 2004).
Love would be considered as more basic thandignity (Macer, 1998). The term love is usually omitted
from international law, whereas the concept of humandignity is often cited. Human dignity is arguably evenmore difficult to define than love. For example, Article
11 of the Universal Declaration on the Human Genome
and Human Rights, states, "Practices which arecontrary to human dignity, such as reproductive cloningof human beings, shall not be permitted" (UNESCO,1997). Why cloning is always against human dignity is
not clear. For example, if it was the only way a family
could have a genetically related child why is thatagainst human dignity? Especially when using donatedsperm and eggs or a surrogate mother is permitted inmany countries, even for commercial contracts. If weare assisting in the formation of a family throughassisted technology, this dies not appear to be against
dignity. Part of the concept of dignity is linked to selfdetermination, so access to technologies to reproduce,
which is a human right, could seem critical for thepreservation of dignity. Yet, at the time following thecloning of Dolly the sheep by nuclear transfer in
February 1997, it became a popular call for many
government leaders to say cloning was against humandignity because of some idea that the new technology
was “unnatural” or going too far. Here we see an
example of how dignity can be used to support bothsides of an argument.
Across the world we can find many common
expressions of dignity from many sources (Macer,2011). It is clear to see the abuse of dignity whenpeople are actually harmed physically, such as inmurders, wars, racial and sexual discrimination, andprohibitions of migration. The dignity of a community isenhanced when all members are well-treated and in
ethical relationships. Sometimes it can appear that acommunity welfare takes precedence over anindividual, but the dignity of a community is maximised
when every member also has dignity in their existence
and relationships.
Kant and inherent human dignity
It is important to emphasize that intrinsic humandignity is a Western construct. Traditionally, Western

philosophy considers it to be objective and seen as
inherent feature of the human person. This aspect ofobjective dignity, in Eastern cultures is supplemented
by a subjective dimension in the sense that humanbeings try to create their own world of life, in what might
be called acquired dignity. This view of acquired
subjective dignity can be observed in Japanese culture.
From an hermeneutical perspective, the person strives
to acquire dignity through moral behavior, actions orpractices. In other words, human dignity is manifested
in an inter-relationships with others, rather than an
inherent condition that people have for the sake ofexisting.
The distinction between hierarchical thinking about
dignity and its character as intrinsic human value isattributable to Kant. The whole theory of human rights
can be anchored on a deep understanding of the ideaof dignity. The categorical moral imperative of Kant is"act only according to that maxim whereby you can at
the same time will that it should become a universal
law" (Kant, 1981). This will, commanded by "purereason is practical and gives only his (the man) a
universal law that we call moral law" (Kant, 2006). In
addition, the categorical imperative regards man as an
end in itself, never as a means. It considers dignity not
as cause but as a result of that imperative.
The Kantian view does not contradict, indeed itcomplements, the Christian maxim "Do not do to others
what you do not want done to yourself," present in all
cultures and religions with different nuances. In thecenter we find the idea of equality contained in the
moral principle of treating others the same way I want
to be treated and the Kantian aspiration that the act ofeach can be elevated to the rank of a universal law.
We may suggest that "dignity is a mirror of thehuman intrinsic condition" (Cornejo, 2014), that which
does not mutate or is modified by sociologicalconsiderations or impaired consciousness, or awards,
claims or any other circumstances. For Kant, which
does not mutate, the permanent is given by the soul,
given as immaterial substance, incorruptible, spiritualand immortal. Kant, in his Third Paralogism of
Personality, said that "what is aware of the numerical
identity of himself at different times is a person.” Now,
"the soul ... then the soul is a person” (Kant, 2006). And
the identity of the person must be unfailingly in my own
consciousness.
If I contemplate myself from the point of view of theother, the outsider begins by considering in time,
because the apperception of time has only been shownin me.
Kant and Mirandola felt that dignity is
manifested in the autonomy, rational human capacity todiscern. Apparently, the progress of science challenged
the thinking of these humanists, who had no chance toconsider what happens in a person in a persistentvegetative state or in advanced Alzheimer's in which
the cerebral cortex is so damaged that they have noawareness of themselves or their environment.
If we apply the criteria of rationality underlying
dignity, according to Kant, these people could not be
considered rational beings and therefore worthy. To

Eubios Journal of Asian and International Bioethics 26 (May 2016)
overcome this problem, according to some authors, theKantian use of the word "dignity", "belongs to the worldof meta-ethics, merely serve as a record that explains,on the one hand, human origin of morality and canreject the aristocratic conceptions of morality, to showthat this capacity for morality is connected withhumanity itself and not having special characteristics”(García-Manriquez, 2009).
Carlos Nino points out that decision on the rights ofcitizens based on a convention called dignity must be
justified on the basis of principles whose basis orvalidity does not depend on the convention. In otherwords, the ideal morality is above the positive morality.
Then, the ideal morality must be based on principles
and neither the principle of the inviolability of the person
nor the principle of autonomy is sufficient to deny theprinciple of dignity. These three principles form part ofthe basis of the principles of liberal constitutionalism
and the set of fundamental rights that are associatedwith this concept (Nino, 1997).
Human rights and dignity
The meaning of the word dignity is certainlycomplex; however, this term has been the essential
basis of numerous declarations, constitutions,covenants and legal documents of global relevance.
The Preamble to the Universal Declaration on Human
Rights of 1948 states that "freedom, justice and peacein the world are based on recognition of the dignity(...)", and the Declaration on the Protection of All
Persons from Torture and other Cruel, Inhuman or
Degrading (1984) states that human rights "derive fromthe inherent dignity of the human person".
Most Latin American Political Constitutions reiteratethese ideas. However the rank and hierarchy accorded
this notion of dignity, as stated above, there seems to
be little clarity or consensus when it comes to thedefinitions and details about their content and meaning.
Indeed,dictionaries
and
the
most
famousencyclopedias do not include the voice "dignity".
The conclusion is already tacit contained in theabove reasoning, the concept of "dignity" is ambiguous,
vague, ethereal, undefined. Lawyers have great
difficulty in arriving at an acceptable definition(Figueroa, 2009). However, on that concept all humanrights are based, from those who were alreadyrecognized in the Constitution or in the Bill of Rights, tothose that have lately taken up the Universal
Declaration on Bioethics and Human Rights (UNESCO,2005). As we can see in the above example ofreproductive cloning, dignity can be used on both sidesof the argument.
Dignity and enhancement
Human dignity will be promoted through theempowerment of all to make well considered moral
decisions.
The International Bioethics Survey
conducted in 1993 in ten countries in Asia and thePacific (Macer, 1994a) found positive views towards
genetic enhancement in China, India and Thailand, withless approval in the Philippines, Singapore, and a

93

majority rejection of this in Japan, Australia and New
Zealand. Eugenic ideas found both positive support insome countries, for example for improving genes bygenetic screening; with less negative reaction, forexample a few people cited social eugenics programs,
or many being against gene therapy for enhancement.
The questions regarding genetic screening and genetherapy suggest positive support for eugenics among asignificant portion of the population, especially in China(Lo et al., 1994), as well as India and Thailand (Macer,
1994b). Subsequent research has also supported thisconclusion that there is significant support forenhancement in the most populous countries in theworld, China and India.
Access to cosmetics is not usually consideredcounter to dignity. Whitening creams are widely used in
East and South East Asia, and it is difficult to findcosmetics that do not contain whitening agents. Even
the dowry prices for ladies to marry is lower for fairer
skins in India, and conversely fairer skin tones inThailand can raise a higher price for the ladies (wheremen pay the dowry). There have been studies ofattitudes to dental orthodontics which suggest Asianpatients are more willing to tolerate discomfort and painfrom realignment of teeth than Caucasian patients(Lew, 1993). Improvement in dento-facial aesthetics
following orthodontic treatment enhances the selfconfidence and self-esteem of a majority of patients –can we say it enhances some sense of dignity. The
same could be said for hair styling and fashion
accessories.
There are some associations between particularpsychological states and tendencies to undergocosmetic surgery (Swami et al., 2009), such as greater
psychological investment in physical appearance andgreater internalisation of mass media images ofphysical beauty (Sarwer et al., 2005). Swami et al.
(2009) found that less open and more emotionallystable individuals had a greater likelihood of accepting
cosmetic surgery in order to maximise its self-oriented
benefits. Such emotionally closed individuals may
maintain more negative evaluations of theirappearance, which leads to a greater acceptance ofcosmetic surgery if it is able to enhance theirappearance. While we could argue that beauty is not
linked to dignity, but the freedom to enhance one’s
perceived beauty through cosmetics is something we
can see in every indigenous culture, and inhibitions on
the freedom of individuals when told that they cannot
enhance themselves seem to be counter to dignity
itself.
Conclusions
We have observed that the construct dignity is partof Western history, although its content has evolved
and requires nuances in interpretation. Perhaps thesame ambiguity and polysemy seen in the use of thisword are guarantees of permanence and widespreaduse. Dignity is also something guarantied by selfdetermination, and can be diminished when choices arelimited by invasive laws and governments.

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

We should ask whether it is the foundation ofhuman rights and is also regarded as a principle andfoundation in Western bioethics. This conception isadopted by the doctrine of human rights. However,other interpretations relate the concept of dignity to his
corollaries, autonomy and inviolability of the person,
establishing the bases of modern deliberative
democracy, which involves participating citizens, whose
arguments no matter how diverse they might be. The
notion is that society can lay the groundwork for aparticipatory democracy and therefore more legitimate
and solid.
Much of the arguments to protect the disabled are
based on ontological dignity, perhaps because dignity
implies a higher cortical development, allowing
discerning and choosing, which is the general rule, butthere are exceptions and the principles should be wide
enough to provide solutions to these exceptions. The
meaning of dignity in its intrinsic ontological conception
is still needed. This interpretation serves to protect
vulnerable people who otherwise would be notconsidered human.
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95

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Developing a ContextSensitive Patient-Physician
Relationship Model for
Health Care in Bangladesh- Md. Munir Hossain Talukder, M.A. in Applied Ethics, Ph.D.
Professor, Department of Philosophy, Jahangirnagar
University, Dhaka 1342, Bangladesh
Email: mdmhtalukder@gmail.com

Abstract
Bangladesh has a complex scenario of patientphysician relationships and there is no single
established model. Several points have indicated that itis necessary to develop a new model. A framework ofideal patient-physician relationships for Bangladesh
which is context-sensitive has been explored in thispaper. It argues that an ideal model should not just be
based on some moral jargon but rather it should also
consider the context seriously. A balance between ideal
and reality is vital. So, illiteracy, scarcity and culturaldifferences are morally relevant and not only practically
relevant. The paper concludes that care ethics will
provide the moral basis of the proposed ideal patientphysician relationship model since people in
Bangladesh, who are embedded with emotions,perceive autonomy as relational rather than individual.
Keywords: Autonomy, beneficence, communication,
context-sensitive, ethics, paternalism, values
1. Introduction
I have discussed elsewhere different patientphysician relationship models in the Bangladesh
context (Talukder 2011). I have argued that there areconsiderable reasons to build a new patient-physician
model for the country. Some of these reasons are: first,
no model pays enough attention on the role of thefamily in making medical decisions which is vital for the
Bangladesh context. The family could be taken as amain entity of care; individuals depend on the family
members when they are ill, in social life, individuals are
sometimes identified by their family, family members
stay in the hospital with patients, share and take carewhen somebody becomes ill. So, the family members
seem to hold a right to help the patient to decide and in
this way the family’s role is morally relevant. Secondly,
the consequences of strong paternalism in the country
are immoral. Thirdly, some physicians devaluate moral
values and are desperate for money. Finally, many
patients are not satisfied with the current patientphysician relationship. Therefore, we need a new typeof relationship which is effective to solve current
problems and to be compatible to the context.

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

In this paper, I will explore what type of patientphysician relationship suits as an ideal in the
Bangladesh context when we want to account for thefacts of illiteracy, scarcity and cultural differences. We
will try to find out the answer whether and why illiteracy,
scarcity and cultural differences are ethically relevant
concepts. In addition, how these three conceptions may
influence to outline a context-sensitive ideal will beanalyzed. It is necessary to mention that some key
aspects of the patient-physician relationship seem
crucial to build a context-sensitive ideal. In our previous
discussion on the models we point out that Emanueland Emanuel have emphasized four key conceptions
and Veatch also analyzed some conceptions as vital.
From my point of view six conceptions - trust andbeneficence, the patient-physician communication,
decision-making authority, the role of the physician, thepatient’s autonomy and resolving the conflicting values
need to be stressed in analyzing an ideal relationshipfor current Bangladesh context. We order six aspects
on the necessity and importance for the current
Bangladesh
patient-physician
relationship.
This
analysis collectively presents an idea of realistic as wellas ideal relationships. The status of context-sensitive
relationship is pragmatic and possible to achieve in
Bangladesh context. These aspects incorporate theminimum requirements so that it makes a balance
between ideal and reality.
Finally, for the moral foundation of this ideal
relationship we will discuss the relevant ethicaltheories.
2. Aspects of a context-sensitive ideal patientphysician relationship in current Bangladesha. Trust and beneficence: Trust and beneficence are
two valuable elements of an ideal patient-physician
relationship in Bangladesh. Achieving the patient’s trust
should be one goal of a physician. Trust will beachieved only when all criteria of effective
communication are satisfied. That is, the patient willtrust the physician when she is careful, does not harm,
maximizes the patient’s benefits, is sympathetic,
selfless, skillful, benevolent, respects the patient’s
rights and autonomy, is communicative and so on. In
an illiterate society trust could be the basis of an ideal
relationship since the disadvantaged people easily trust
their physician. They consider their disadvantage as aserious lack and trust the physician to do what is in
their best interest. The patient-physician relationship is
ultimately a bond of trust. As Beauchamp and Childress
write,“...relationships
betweenhealthcare
professionals and their patients...ultimately depend on
trust, and...rules of veracity is essential to foster trust”(Beauchamp and Childress 2001, p. 284).
Beneficence is the other major foundation for theideal relationship. Pellegrino and Thomasma holdbeneficence as the “guiding principle” of the patientphysician relationship. Indeed, they propose a newterm namely “beneficence-in-trust” which incorporates
other moral principles. What does “beneficence-in-trust”
mean? Pellegrino and Thomasma write, “Bybeneficence-in-trust we mean that physicians andpatients hold “in trust”...the goal of acting in the bestinterests of one another in the relationship” (Pellegrino
and Thomasma 1988, p.54).
b.
The
patient-physician
communication:
Communication gaps or miscommunication is a serious
issue for Bangladesh. Ideally for the correctunderstanding of the patient’s problem, clarifying andcollecting necessary information, discussing about thedisease and possible treatment require a considerable
amount of time. Indeed, we have stated in the
introduction that Bangladesh has a large population;and scarcity is a major problem there. So, the physician
may not be able to allocate too much time for a patient.
An effective patient-physician communication makes asignificant relationship. Effective communication
eventually results in patient’s satisfaction. Sometimes
effective communication is as important as medicine.
Travaline et al. (2005) write, “In fact, research has
shown that effective patient-physician communication
can improve a patient’s health as quantifiably as many
drugs...” (p.13).
So, effective communication is a skill and an ideal
patient-physician relationship should include this skill.
Now, what are the conditions or criteria of effective
communication? According to the Accreditation Council
for
Graduate
Medical
Education,effective
communication skills have five elements: “1. listening
effectively 2. eliciting information using effective
questioning skills; 3. providing information using
effective explanatory skills; 4. counseling and educating
patients; and 5. making informed decisions based on
patient information and preference” (Travaline et al.
2005, p.15).
The Bangladeshi patients often cannot reach thephysician on time because of the scarcity of transportand medical resources. Illiteracy is another barrier for
effective communication. We cannot set the ideal thatthe physician will spent a set time, e.g. an hour for apatient and communicate with the patient in a technicallanguage which is sometimes essential. However,considering the context an ideal communication could
be providing true information in an easy language which
the patient wants to know. This would create anenvironment where the patient feels free to disclose
confidential information about the disease. As a whole,
the patient will be fully satisfied after communication.
c. Decision-making authority: Medical decisionmaking is a complex issue. We are uncertain about the
future risk and have to depend on the present available
information. Our knowledge, wisdom and experience
helps us make the most prudent decision for us.
However, when there is a question of life and death,taking risk for future benefit; the decision is crucial. Whoshould decide in the patient-physician relationship? As
we know most of the patients in Bangladesh are
illiterate and poor. Are the illiterate and poor people
capable of making their health care decision? Are they
competent enough when they have not received any
formal education? Is the family’s participation inEubios Journal of Asian and International Bioethics 26 (May 2016)
decision-making process morally acceptable? These
questions need to be answered.
A common and immediate argument could be that
uneducated, illiterate people are unable to understand,communicate and use information, therefore, thephysician should decide for them. Paternalism isappropriate for this class of patient. Yet, Luna has
rejected this argument as unsound and shows that
illiterate people are not incompetent to make medical
decision. She analyses three possible meanings of thisargument. Firstly, communication with illiterate people
is “impossible” hence they are incompetent. Secondly,
as the illiterate people are unable to use the information
they are unable to understand. Thirdly, even if illiterate
people are competent they might have some additional“difficulties” such as fears, psychological and mental
blockings to understand and communicate properly.
According to Luna, the first interpretation is unfair andtoo strong as it denies that illiterate people possess
basic human values. The second interpretation is
mistaken by confusing information and understanding.
That illiterate people cannot read and write does not
imply that they don’t have “cognitive faculties” tounderstand. The third interpretation is plausible but it
might also be applicable to the literate people.
Therefore, Luna concludes that if the physician
interprets health problems in an easy language by
giving some additional “time and effort”, the illiterate
people can make their own decision (Luna, 1995,
pp.286-289).
Luna’s conclusion is not fully acceptable. It isdifficult to agree with her that there is no difference
between the educated patient and the uneducatedpatient to make medical decision. That is illiteracy does
not matter in making medical decision. An educatedpatient may able to decide by using information, riskbenefit analysis and so forth. But it might not be easy
for an illiterate patient. An illiterate patient could choose
among the options, but their choice may not be
rationally justified. Ideally, the patient should have theauthority as he or she is the owner of his or her bodyand possess the right to decide. Nevertheless, whenilliteracy prevails the patient may not able to decidealone without any discussion. As Clarke et al. write,“Our experience indicates that many patients do notwant to decide alone, however; they prefer family or
friends to be involved and they want advice from a
spouse, son or daughter before they make the final
decision” (Clarke et al., 2004, p.16). So, it may not be
pragmatic to say that the illiterate patient has theabsolute authority to decide. We have to consider theirreasoning limitation, low cognitive ability and so forth.
There is nothing wrong if the physician or the family
helps them to decide.
Another feature needs to be considered is cultural
circumstances. In a Bangladeshi culture, the patient’s
family members or relatives attending him or her havean influence to make the final decision. Generally, thephysician informs the patient’s condition, risks andbenefits to the family members if he or she being
asked. Although the patient may not participate in this97

discussion the family conveys the information. So, therole of the family is crucial. In an ideal relationship, thepatient will directly participate into the physician’s
interpretation, explanation or suggestion and may seekfamily members’ or intimates’ advice before preferring
the final decision.
d. The role of the physician: Different ethicists
propose different roles as ideals for physicians. We
have seen Emanuel and Emanuel propose the idealrole of a physician as a moral deliberator while Veatch
proposes as a contractor. But we cannot apply theirideals in Bangladesh context as most of the patientsare illiterate, poor and they want family involvement inmedical decision-making. The illiterate and poor patient
has a chance to be treated paternalistically andsometimes the physician could abuse them for theirpoverty and ignorance. In considering this practicalsituation, in our ideal model the physician’s role may
not be confined. Giving proper treatment, providing
correct and true information, building a trustful andcordial relationship, counseling health care values,
interpreting and discussing patient’s condition with
passion, sympathy, and respecting patient’s rights are
the basic role of a physician. Although in a
disadvantaged society the physician’s role is defended
as, “...when important decisions are to be made thedoctor feels justified in overriding the patient’s wishes.
The doctor may subscribe to the view that patients do
not have sufficient knowledge to make gooddecisions...” (Mckinstry 1992, p.341).
This traditional attitude should be changed. As Huiargues for interpretive model instead of traditional
paternalistic model in Chinese tradition by saying that,“A Chinese PPR [Patient-Physician Relationship]...fits
well in the “Priestly”/ “Paternalistic” models that areincompatible with modern medical codes...educatingand enabling their patients to properly exercise theirright of autonomy so that...outcomes can be achieved
through the ideal “interpretive”/ “collegial” PPR model.”(Hui 2005, p.223)
So, we could suggest that instead of taking theeasy way out, the physician should make an effort tobuild a caring relationship with their patients andexplain, advise health care rights and values.
e. The patient’s autonomy: The concept“autonomy” originates from the Greek words “autos”
means “self” and “nomos” means “rule”. So, the literary
meaning of the word “autonomy” is “self-rule”. While
applying to the individual level autonomy refers right tochoose, right to liberty, right to privacy and so on(Beauchamp
and Childress, 2001, pp.57-58).
Autonomy is a fundamental requirement for an ethicalpatient-physician
relationship.
Acknowledging
apatient’s autonomy implies that the patient is capable ofmaking his or her own decision, able to choose orrefuse any treatment, conscious about the health carevalues and so forth. According to Childress, autonomy
has two important features: “acting freely” and“deliberating rationally”. Acting freely refers to acting
without others coercion or influence. An autonomous
act is free and voluntary. On the other hand,

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

deliberating rationally means the deliberation of“imaginative” rational action. (Childress 1982, p.62).
Now the questions are: who is an autonomous person?
Can the poor and illiterate patients fulfill the criteria of
autonomous personhood? Is autonomy ideal or
relational?
According to Beauchamp and Childress, anautonomous person is able to act freely, he or she has
a “self-chosen plan” while a person lacks autonomy
when he or she is unable to act according to his or her
self-chosen plan and “controlled” by someone. They
hold that “autonomous choice” is the basic criterion to
be treated as autonomous (Beauchamp and Childress
2001, p.58). The poor and illiterate patients may nothave self-governing capacity in a standard sense, i.e.
draw conclusion by a sound reasoning process,analyze and use health care information and values
and so on. Still, they are able to make a choice forthem. They have the capability of choosing the mostsuitable option and in this sense they are autonomous
persons.
Autonomy might not be the goal of the patientphysician relationship rather a condition for asatisfactory relationship. As the poor and illiteratepatients lack some criteria of autonomy such as rational
self-governance their autonomy is not individualistic but
rather relational.
f. Resolving the conflicting values: The patient’s andthe physician’s values may conflict in their relationship.
The causes of conflict could be inequalities in healthcare knowledge, social status, religion, moral belief andso on. Illiterate people might have dogmatic attitude,
false belief or misperception of religion. As a result,
their values may conflict with the values of thephysician. Indeed, the same holds for the physician.
Their attitude toward medical science, hierarchicalsocial status and different moral values may conflictwith the patient’s values.
Different authors have proposed different ways toresolve this conflict. According to Childress, theseconflicts may not be reducible to a single moral
principle. We need better understanding andinterpretation to resolve the conflict. A plurality ofprinciples, collective justification may help to make aharmony between conflicting parties (Childress 1982,p.72).
Veatch says that there are three ways to resolve
conflict. First, we could choose a single generalprinciple. Second, we may rank the conflicting
principles by lexical ordering, and third, we may seek
the balancing principles that possess equal status.
However, Veatch rejects all of these alternatives andpossesses an alternative of exploring (Veatch 1981,
pp.295-305).
Pellegrino and Thomasma have suggested “rationalorganizing” of the conflicting principles on the basis of“beneficence-in-trust” criterion. Their proposal has two
schemes: “procedural” and “metaethical”. According tohim, the procedural scheme includes: patient’s
directives,
patient’s
negotiatedvalues,proxyjudgments, ethics committee, legal system while

metaethical scheme includes: the last good, patient’s
good, particular good and the biomedical good
(Pellegrino and Thomasma 1988, pp.84-91).
As the patients are illiterate they might have a blind
belief or conservative idea about the health care values
as I just mentioned. So, we cannot set out our ideal thatthe physician and the patient will rationally resolve theirconflicting values rather they could resolve theseconflicts in a customary way. That is, dialogue orcounseling could be appropriate for resolving conflicting
values. By counseling the patient may rectify theirvalues which will help them in the long run as well as
the physician has an opportunity to review his or her
particular values. By dialogue both parties will
understand each other more clearly and able to find out
a common ground between them.
To conclude this section, we have shown that it isdifficult to set up a high standard ideal for the
Bangladesh context. Since such type of ideal will be
unreachable or utopian. We cannot ignore the threecontexts particularly illiteracy, scarcity and culturaldifferences to have an ideal relationship. The proposedcontext-sensitive ideal is possible to fit for Bangladesh.
These factors matter morally. Further, for the moral
basis of this relationship we need ethical theories. An
ethical theory will guide the physician as well as thepatient to act morally. Theories could be exercised andused to overcome the current problematic situation.
Therefore, in the next section we will concentrate on therelated ethical theories.
3. A brief discussion on related ethical theories
An ideal patient-physician relationship must be
supported on moral grounds. What should be the basisof an ideal relationship: utility, rule or care? Twoprominent approaches to evaluate the moral
permissibility of an action are: utilitarianism anddeontology. The moral standard of utilitarianism is‘utility’ while for deontology it is ‘moral law’. We may
reach two different conclusions by following
utilitarianism and deontology in the same case (e.g.
truth telling or lying). So, we cannot solve many moral
dilemmas in the patient-physician relationship by thesetwo principles. To overcome this problem a new moral
approach has developed, namely, care ethics. Careethicists claim that some moral problems are better
solvable by taking ‘care’ as a moral standard. We will
discuss these principles in this section.
I. Utilitarianism: Utilitarianism is a widely applicableethical theory in biomedical ethics. Utilitarianism asks
us to calculate utility and make decisions by maximizing
utility. The chief characteristics of utilitarianism is statedas, “...there is one and only one basic principle in
ethics, the principle of utility. This principle asserts that,in all circumstances, we ought to produce the greatest
possible balance of value over disvalue for all persons
affected” (Beauchamp and Childress 1983, p.20).
From the above definition, we may say that firstly,
the fundamental principle of utilitarianism is utility i.e.
the morality of any action is justified by the utility.
Secondly, we should maximize the value of the goodEubios Journal of Asian and International Bioethics 26 (May 2016)
consequences over bad consequences. Thirdly, we willcalculate the value in consideration to a utility calculus.
Jeremy Bentham and John Stuart Mill are the mostprominent philosophers in utilitarian tradition.
Now, we may clarify: what is utility? And whose
utility should be maximized? Utility is something which
we want for itself and not for its consequences. That is,utility is intrinsically valuable and all other things are
extrinsically valuable. But ethicists have different
opinions about the intrinsic value. Some ethicists (e.g.
Mill and Bentham) hold that “happiness” or “pleasure” isintrinsically valuable while others (e.g. G. E. Moore)
hold that “knowledge” or “beauty” could be intrinsicallyvaluable. The former approach is known as “hedonism”
while the later is “pluralism”. The solution is that theindividual will decide which value is greater to him orher (Beauchamp and Childress 1983, pp.24-25).
Should the individual consider any particular ‘act’ or‘rule’ to justify an action? There are two answers tothese questions. Act utilitarians hold that “particular
circumstances” are important to determine therightness or wrongness of any action while ruleutilitarians hold that “justified rules” are valuable todetermine the rightness or wrongness of any action(Beauchamp and Childress 2001, pp.342-344). Whileact and rule utilitarianism differ about the means of thejustification, both of these theories agreed that weshould maximize good consequences over bad
consequences. The consequence of an action is thedeterminant of its moral permissibility. Utilitarianism isthus a consequentialist theory.
How does utilitarianism reply against illiteracy,
scarcity and cultural differences and the patientphysician relationship? As the consequences of an act
are the main considerations of utilitarianism, utilitarians
will argue for the maximum benefit of scarce resources.
For this reason they may support paternalism. For an
illiterate society paternalism is justified from a utilitarian
perspective by considering time, the patient-physician
ratio, insufficient medical infrastructure. However, wehave seen that paternalism is no more acceptable as
an ideal model and in addition the consequences ofpaternalism in Bangladesh are terrible. Utilitarianism
may not consider individual patient’s welfare. Since thegreatest happiness of the maximum number of people
is the ultimate goal of utilitarianism. Utilitarianism may
not consider relationships rather the equal distributionof health care services is desirable. As a result thisethical theory may not contribute to the illiterate poor
patients.
II. Deontology: Deontological theory rejects utilitarian
standards of morality and claims for a reason andobligation-based moral principle. Immanuel Kant
formulated the core principles of a deontological theory
which he calls the “categorical imperative”. All ethicalrules derive from the conception of the categoricalimperative. Kant’s first formulation of the categoricalimperative is, “Act only on that maxim through which
you can at the same time will that it should become auniversal law.” (Mappes and DeGrazia 1996, p. 17).
The second formulation says, “One must act to treat

99

every person as an end and never as a means only”(Beauchamp and Childress 2001, pp.350-1).
These two principles have large influence on
biomedical issues. Apparently, it seems that when weuse human beings as an organ donor or researchsubject we violate Kant’s second principle but
Beauchamp and Childress argue that in those cases
we do not use human beings as “merely”, and Kant
allows using persons who have given consent(Beauchamp and Childress 2001, p.351).
Kant’s ‘principle of autonomy’ protects respect for
persons and imposes three duties on us to others: “1.
the duty not to kill an innocent person 2. the duty not tolie and 3. the duty to keep promises” (Mappes and
DeGrazia 1996, p.18). Now, we may consider theseprinciples in the patient-physician relationship. Should
the physician ignore patient’s autonomy? Is lying
morally acceptable? If we follow Kantian principle theanswer of these questions are ‘No’. In any situation thephysician should not lie to the patient and the patient’s
autonomy must be protected.
How will deontology respond to illiteracy, scarcity
and cultural differences? Deontology offers us such an
ideal conception that in any situation whether literate or
illiterate the patient’s autonomy should be treated asuniversal. Deontology emphasizes rationality andreason and argues that moral rules are always
absolute. According to Kant, “The principle ofautonomy'...is “the sole principle of morals”, andautonomy alone gives people respect, value and proper
motivation” (Beauchamp and Childress 2001, p.351).
But practically it is difficult to accept that theilliterate, poor people could realize or able to apply her
autonomy in a Kantian standard. Moreover, the culturaldifferences of Bangladesh do not permit that the patient
will decide autonomously ignoring family’s association.
It does not imply that the family undermining thepatient’s autonomy rather the patient is embedded in
the family and as a result the family members have aright to decide for the patient. So, deontology will notconsider the reality of illiteracy, scarcity, and culturaldifferences and strict to apply the universal moral law inall situations.
III. Care ethics: The care ethics values ‘care’ as theprime criterion of morality and rejects the notion of‘impartiality’ in moral thinking. Care ethicists highlightsome human qualities such as care, empathy,
sympathy, relations, which are more acquainted withthe feminine gender and are morally relevant.
According to van den Hoven, “Care ethicists hold thatcare should be accepted as a central moral notion,
because care is what moves people, what stimulates
them to act, and from which our legitimate expectations
to others derive and are negotiated” (van den Hoven
2006, p.93).
The care ethics originates from the feminist
approach of morality. Carol Gilligan’s work In a different
voice (1982) contributes remarkably to develop “thevoice of care” (Manning 2001, p.99). Why is ‘voice ofcare’ morally significant? van den Hoven interprets this100

Eubios Journal of Asian and International Bioethics 26 (May 2016)question very clearly. She points out that Gilligan’s
works give us a “positive interpretation” byreconstructing traditional negative interpretation of careassociated with women and concedes care as amorally valuable notion. She states Gilligan’s view isthat women are more caring to maintain relationshipwhereas men are concern about “moral rules andjustice”. So, women possess a different approach thanmen to articulate a moral judgment. (van den Hoven
2006, p.93).
According to van den Hoven, an ethics of careprovides special emphasis on persons. As she writes,“To conceive of care as a primary moral notion implies
that we have to acknowledge that morality and moral
deliberation take place within dynamic practices inwhich the concrete attention to persons is of utmost
importance” (van den Hoven, 2006, p.94).
Another vital characteristic of care ethics is that it iscontext-sensitive and denies “universality” as well as“impartiality” as preconditions of moral deliberation.
However, a care ethicist does not refuse wholly these
two notions rather argues against their necessity as a“starting-point” for “moral deliberation” (van den Hoven
2006, p.95).
Joan Tronto indicates that care ethics is not only
helpful to make a balanced, interconnected ethicaldecision but also to eliminate all oppression against
women. By forwarding a step further Susan Sherwin
claims that we can apply care ethics to solve bioethicalproblems (Dodds 2000, p.222). The main theses ofcare
ethicsarevaluing
relationships
andinterconnectedness. This theory discourages isolationand tries to solve the debates that arise by following
isolated autonomy-based bioethics. Dodds mentions,“The care focus gives us an awareness of therelationships between people and the ways these
relationships are affected by health care” (Dodds 2000,
p.222).
How can care ethics contribute to our ideal patientphysician relationship? Care ethics emphasizes on
caring as a moral phenomenon and in the patientphysician relationship a mutual understanding is
expected. The basic structure of this relationship could
be contractual, deliberative or one of the others
discussed earlier. Indeed, the care could provide an
extra advantage and resolve contradiction arises by
self-interest in a single principle. As van den Hoven(2006) writes, “The fact that care is our central moral
notion implies that being attentive to the needs ofothers is a moral quality of agents and failure to see
and meet the needs of others will be morally
reproachful.” (p.97).
The conflict of interest might sometimes be much
more difficult to resolve. Only care attitude could makea reasonable and acceptable solution of these
problems. As Purdy (1992) says, “Should doctors lie tocover up negligence? Should they suggest
unnecessary surgery to make an extra buck? Should
we invest in strategic defense initiatives when AIDS
patients languish without care? Everybody knows theanswers: the question is whether we care enoughabout others to do the right thing” (p.10).
The illiterate, poor patients highly expect a caring
relationship with the physician. They may not have theability to analyze information, value of informed
consent, standard competency and sense of autonomy
but they surely feel how much a physician is caring tothem. We may claim that many ethical dilemmas,
negligence and medical malpractice will be reduced
greatly if this humane principle is included in
Bangladesh health care practice.
4. Conclusion
To summarize, in this paper I have tried to build up
a framework of ideal patient-physician relationships for
Bangladesh which is context-sensitive. Our hypothesis
was to offer an ideal model where context matters. We
have made a balance between ideal and reality byincorporating the minimum requirements. So, illiteracy,
scarcity and cultural differences are possibly morally
relevant and not only practically relevant. The care
ethics will provide the moral basis of our ideal patientphysician relationship. Since the poor, illiterate,embedded people perceive autonomy as relational andevaluate their relationship by sympathy, empathy andcare.
References
Beauchamp, Tom L. and Childress, James F. (2001).
th
Principles of Biomedical Ethics, 5 edn. New York: Oxford
University Press.
Beauchamp, Tom L. and Childress, James F. (1983).
ndPrinciples of Biomedical Ethics, 2 edn. New York: Oxford
University Press.
Childress, J. F. (1982). Who Should Decide? Paternalism in
Health Care. New York: Oxford University Press.
Clarke, G., Hall, R.T. and Rosenerance, G. (2004). PhysicianPatient Relations: No More Models. The American Journalof Bioethics Volume 4 Number 2, 16-19.
Dodds, S. (2000). Choice and Control in Feminist Bioethics.
In: Mackenzie, C. and Stoljar, N. (eds) (2000). Relational
Autonomy. Feminist Perspectives on Autonomy, Agency,
and the Social Self. New York: Oxford University Press,
213-235.
Hui, EC (2005). The Centrality of Patient-Physician
Relationship to Medical Professionalism: An Ethical
Evaluation of Some Contemporary Models. Hong Kong
Medical Journal Vol. 11 No. 3, 222-223.
Luna, F. (1995). Paternalism and the Argument from Illiteracy.
Bioethics Volume 9 Number 3/4, 283-290.
Manning, R.C. (2001). A Care Approach. In : Kuhse H., andSinger P.(eds). A Companion to Bioethics. Oxford:
Blackwell Publishing Ltd. 98-105.
Mappes, T.A. and DeGrazia, D. (eds) (1996). Biomedicalth
Ethics. 4 edn. New York: McGraw-Hill Inc.
McKinstry, B. (1992). Paternalism and the Doctor-Patient
Relationship in General Practice. British Journal of General
Practice 42, 340-342.
Pellegrino, E.D. and Thomasma, D. C. (1988). For the
Patient’s Good. The Reconstruction of Beneficence in
Health Care. New York: Oxford University Press.
Purdy,L.M (1992). A Call to Heal Ethics. In:Holmes, H.B and
Purdy, L.M. (eds) (1992). Feminist Perspectives in Medical

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Ethics. Bloomington and Indianapous: Indiana University
Press, 9-13.
Talukder, M.M. H. "On Patient-Physician Relationships: A
Bangladesh Perspective", Asian Bioethics Review , Vol. 3,
No. 2, pp. 65- 84, June, 2011.
Travaline,J.M. ,Ruchinskas, R. and D’Alonzo, G.E. (2005).
Patient-Physician Communication: Why and How. The
Journal of the American Osteopathic Association Volume105. Number 1, 13-18.
van den Hoven, M. (2006). A Claim for Reasonable Morality.
Commonsense Morality in the Debate on the Limits ofMorality. Quaestiones Infinitae. Volume LII. Utrecht: Utrecht
University.
Veatch, R. M. (1981). A Theory of Medical Ethics. New York:
Basic Books.

Violence and terrorism in
the Middle East
- Nader Ghotbi, Ph.D.
Ritsumeikan Asia Pacific University (APU), Beppu, Japan
Email: nader@apu.ac.jp

Abstract
Recently, there has been a lot of debate on whether
Islam is similar or different from other religions
regarding the potential to incite violence/terrorism.
Some researchers claim that Islam as a religion may
not incite violence and/or terrorism any more than othermainstream religions, and refer to the fact that the
majority of Muslims are peaceful. Others suggest thatthe majority of recent terrorist attacks are committed bycertain groups of Islamic fundamentalists known as
Salafi Jihadists and violent aggression including
terrorist attacks is more common in parts of the world
where Salafi Muslims live, such as in the Middle East. A
third group explains that many areas in the Middle East
have been impacted by sociopolitical conflict, war andfailed states thus making them vulnerable for terrorism;
therefore the association with Islamic fundamentalism
is only secondary to geopolitical issues. This article
examines some of the common beliefs among Islamic
fundamentalists in order to demonstrate if and how
aggression may be incited and aggressive violence
including terrorism be justified in this worldview. It isdemonstrated how a strict emphasis on puremonotheism(tawheed),sovereigntyofGod(hakimiyyat), a belief in God’s omniscience (ilm) and
predestination (qadar), emphasis on right ‘intentions’(niyyah) rather than right actions, and unequal
treatment of humans based on religious beliefs are ‘risk
factors’ that may incline some salafi (fundamentalist)
Muslims towards jihadism. The article concludes bysuggesting awareness programs to help reform thephilosophical worldview of Salafi communities byfocusing on the value of life and Islamic humanism.
Keywords: Islamic fundamentalism, monotheism,
Muslims, omniscience, predestination, salafi jihadism,
terrorism.

101

Introduction
The increasing number of terror attacks by Islamic
fundamentalists who claim to have followed on theirIslamic teaching has caused a controversy both in the
public and among academicians on whether Islam is apeaceful religion or it incites violence per se. Someacademics argue that many other religions haveteachings that could be misused for rationalizing
violence, and that the recent increase in the number ofterror attacks is related to geopolitical changes
including the invasion and occupation of Afghanistan by
the Soviet Union in 1980s and the invasion of Iraq by
the US forces in 2003. Others hold that not all terrorist
attacks may be attributed to such geopolitical issues
and many attacks have been committed even in conflict
free places by radical Muslims who were barely
affected by the mentioned calamities.
Some researchers (Henslin, 2009) have asserted
that none of the religious terrorists, whether Muslim,
Christian, Jew, or Hindu, etc. represent the mainstreamof their religion. There are usually well known elementsthat appear to incite some religious people towards
terrorism; first, they believe that they are under attackby a rival religious group (for example by Christian
troops in Iraq, communist Russians in Afghanistan,etc.). Second, they are convinced that God wants theirrivals destroyed. Third, they have concluded that
violence is the only solution to the problem. Fourth, they
believe that God has chosen them for this task, andfifth, the community they belong to nurtures such pointsof view. Under these circumstances their moralitychanges into a form that justifies killing for the rightcause.
Karen Armstrong (2001, 2007 and 2014) is a wellknown author on the history of religions in general, andon the history of Christianity and Islam in particular. She
has also authored a book about the relationshipbetween religions and violence throughout history. She
explains (Armstrong, 2014) that violence is usually
covered by a religious cloak, while the real reasons forviolence have often been in the political context. In
other words, political conflict has often framed religion
as the source of violence. In the case of Islam, she
describes how the early Muslims preferred peace andwould only turn to fighting in defense. However, after alarge Islamic empire formed and needed a tool toestablish political order, violence became a morecommon issue in Islam; the same thing had happened
with Christian empires before. Even so, Muslim leadersusually had the “people of the book” including Jews andChristians under protection.
Reading Armstrong’s book, one may conclude that
religion throughout history has influenced the form ofpolitical governance because people have commonly
believed that religion would bring significance to any
social movement. However, the source of violence has
almost always been the state which colored its politics
with religion. Armstrong recommends against blaming
religion for violence and reminds us that nationalism
has far more often been used to incite violence.
Therefore, one may conclude that the association

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

between violence and any religion including Islam is nota causal relationship but is just a correlation.
Frazer (2011), Jones (2014) and Turner (2010,2014) explain in detail the role of Salafism and theSalafi movement in the formation and organization ofterrorism based on a religious ideology. It is worth
noting that even among the Salafi, most are purists orquietists, while a small percentage estimated at 10%
may become politically active, with a much smaller
number of the latter choosing to support or join Salafi
jihadism. However, the existence of this chain points tothe possibility that there may be ‘risk factors’ in thesalafi worldview that increases the chances ofcommitting acts of terror and violence under the nameof religion. Therefore, this paper attempts to explore if
there are ‘philosophical’ beliefs influencing theworldview of Islamic fundamentalists, and reflected incommon beliefs shared by most Muslims, which explain
why a radical salafi Muslim may be more prone to theuse of violence in a conflict.
Methodology
This research is partly based on a review of theliterature about Islamic fundamentalism and salafi
principles and a few academic papers and books
published on this subject, and partly on qualitative
research using focus group discussions with a small
group of radical Muslims believing in or familiar withsalafi views, from Afghanistan and Pakistan. The
findings of literature review were put forward for‘discussion’ by the members of the group, while notes
were taken from the discussion for more detailed
analysis.
Members of the group discussion were all serious,
strict Muslim men who were made assure of anonymity
and in exchange were asked to honestly reflect on theirsolemn opinions regarding Islamic fundamentalism andviolence. None of the group members were salafi
jihadists nor did they support the violence committed by
the associated groups, though they provided their viewof what the ideology behind the violent actions of thesegroups was. The group members did not support
violence committed by the group called Taliban thoughsome were sympathetic to the reasons (such as
governmental corruption) why such actions werecommitted. However, they were quite familiar with theworldview of members of Taliban and their teachings.
An ethical explanation on the use of the information
was provided and oral consent was taken for the use of
the shared information only for research purposes. The
discussion started by asking a series of questions thatare listed in Table 1. Notes were taken and screened
for concepts that were both related to the topic of thisresearch and also were held in common with othermembers of the study group. The ensuing debate wasanalyzed.
Table 1: The main questions used in the focus group
discussion to invoke a critical debate
A- Why is there suffering in the world? What is theIslam’s answer to the question of human suffering?

B- What is the scope of God’s knowledge? How does
it affect human freedom and fate?
C- What duties does a man have towards God and toother people? How are these duties different?
D- Among acts, intentions, and consequences of acts,
which one is the basis of morality?
E- Is there any difference in the value of humans, andif so, what is it based on?
F- How do you explain the violence that exists among
Muslims living in the Middle East?
G- How can one help reduce violence among Muslims
living in the Middle East?
Findings
I shall first summarize the findings of literature
review about the topics that were put into qualitative
research discussion through the questions outlined inTable 1. The ensuing group discussion and debate
helped with a better ‘tuning’ of the information while
participants confirmed some parts and added
explanation to others along salafi (fundamentalist)
Islamic views. Thus, following the findings of theliterature review, these points will be discussed.
Monotheism (tawheed): The first question that any
belief system based on one almighty God should
answer is related to the presence of evil in the world(Abel, 2004). Basically, if there is an almighty andpowerful God as the source of all creation, how can evil
exist? An almighty God would not create evil, nor could
it be forced by other forces to allow evil to exist.
However, evil exists in this world and is not limited tohuman misdeed. There are many natural causes of
disease such as pathogenic bacteria and parasites,
harmful chemical and physical agents of disease, as
well as natural disasters including earthquakes andfires, etc. which cause a lot of suffering for all living
things including humans. In fact, one of the questions
that the first group of Muslims asked Prophet
Muhammad was why there was so much suffering for
Muslims.
If one believes in the existence of another major
power to support evil, such as the devil or Satan inChristianity, evil can be ascribed to the devil andgoodness can be ascribed to God. However, theprophet of Islam firmly believed in only one God; thedevil is not such a powerful entity in Islam and may only
tempt humans to do wrong and lacks the power toinfluence the world by itself. Therefore, the Prophet
explained that suffering was coming from God just as
his mercy, for a number of reasons:First, humans do not have the wisdom of God toknow that suffering was really evil. For example, natureincludes many forces that humans do not know well,and though they may consider them to be evil, it isbecause of their incomplete understanding. Only God
has full knowledge of everything and therefore God’s
perspective of what is evil and what is not would matter,
not the incomplete perspective of humans.
Second, suffering of the Muslims in this world could
be a test of their true faith, and may reduce from theirsuffering in the afterlife and also lead to rewards that

Eubios Journal of Asian and International Bioethics 26 (May 2016)
are promised for the faithful. Therefore, Muslims havebeen encouraged to change their view of what is
usually considered as evil; death, suffering, anddestruction come from God, with his knowledge andwill, just as life, pleasure and growth also come by
God’s will. Therefore humans should generally learn to‘accept’ pain, suffering and death as the will of God,and ‘surrender’ themselves to the will of God. In otherwords, in Islam no one suffers without God’s will.
Omniscience (ilm) and predestination (qadar): In
Islamic theology, God is the all-powerful and allknowing creator. Quran describes God as being fully
aware of everything that happens in the universe,
including private thoughts and feelings, and asserts that
one cannot hide anything from God:
Quran 3- 29. Say (O Muhammad): “Whether you
hide what is in your breasts or reveal it, Allah knows it,
and He knows what is in the heavens and what is in theearth. And Allah is able to do all things.”
Quran 10: 61 “And you are not engaged in any
matter or recite any of the Quran and you do not do any
deed except that we are witness over you when you are
involved in it. And not absent from your Lord is any partof an atom’s weight within the earth or within theheaven or anything smaller than that or greater but that
it is in a clear register.”
Quran 49:16: “Say, would you acquaint Allah withyour religion while Allah knows whatever is in theheavens and whatever is on the earth, and Allah knowsof all things?”
Knowing all things includes knowing what all
humans will do in the future. Some Muslims believe that
there is no way to change what has already been
destined to happen, known as predestination (qadar).
However, fortunately most Muslims respond by sayingthat this rule applies only to nature but not to humans
who have been given a free will and responsibility tomake the right choices and decisions they freely make.
Therefore most Muslims agree that humans have been
given free will by God and only evil humans would
commit evil. But how does a Muslim know if what he isdoing is right or wrong?
As discussed in the previous case, both life anddeath come from God and only God knows what is rightand what is not. So how can one know what one isdoing is right, when the true knowledge of right andwrong is with God? This question brings us to the next
two concepts.
Emphasis on right ‘intentions’ (niyyah): In
general, any deed can be broken down into threecomponents: intention, action and consequence.
Islamic fundamentalists, including salafi jihadists in
Afghanistan and Pakistan appear to believe that thecomponent that matters the most is the ‘intention’ tofollow the God’s will (that may be worded to them by areputable Islamic clergy as the leader), as well as the‘consequence’ (victory for Islam and Muslims, defeat forinvading infidels who are forced to leave) rather thanthe ‘action’ itself. Therefore a salafi jihadi may “intend”
to follow the will of God “in order to” bring victory to
Islam, and he thus may have to commit actions of103

violence that “under normal circumstances are notpermissible”, such as killing a human.
Prophet said: “Deeds are [a result] only of theintentions [of the actor], and an individual is [rewarded]
only according to that which he intends.”
This hadith clearly suggests that actions are judged
according to intentions.
Prima facie duties: Ethics in Islam is not purely
deontological. In Islam, actions are not simply divided
into right and wrong; each person at any moment may
have a number of obligations some of which are more
important than others. A Muslim decides to conduct a
series of actions as “duties”, and to refrain from otheractions that are to be avoided, based on a proper
ranking of them. Basically, humans are always held
responsible for duties they have towards God, such as
in worshipping him only. These actions need to befollowed with almost no exception. This does not meanthat duties to other humans especially fellow Muslims
can be forsaken, but emphasizes on the priority; if
commitment to one duty is incompatible with the otherone, duties to God are the ones with priority.
Also, in general there are many ranks of necessity
for the various actions by a Muslim, as to hownecessary it is to do or ‘not’ to do (to refrain from doing)certaindeeds.
Generally
speaking,
fromareligious/ethical standpoint all actions are classified into
five broad ranks as the following:
1- Wajeb (“fariza”) refers to obligatory actions whichmust be done, when possible.
2- Mostahab refers to actions that had better be done,
but mostly are not obligatory.
3- Mobah refers to neutral actions with a neutral
ethical status meaning that there may be no obligationor duty to do or to refrain from doing those actions.
4- Makruh refers to actions that had better be avoided
but are not fully prohibited.
5- Haram refers to prohibited actions which must be
avoided, if possible.
This classification is a general guideline for overall
decision-making. Interestingly, actions considered‘mostahab’ are right actions which one may still choose
not to do and actions considered ‘makruh’ are relatively
wrong actions which one may still choose to do. The
category of ‘mobah’ actions is not such an inert one
either; commonly it signifies that the judgment to do or
not to do an action is left to the person because no
moral obligations are attached to the act. An example
would be the looseness of the obligation to tell the truth
to a non-believer.
Moreover, under given circumstances, some actions
that belong to one certain category may move toanother category. For instance, eating pork in Islam isgenerally well recognized as forbidden (‘haram’) but ina case that the life of a Muslim depends on eating pork,
for example when no other food is available and hemay starve to death, it may be acceptable (‘mobah’) or
even obligatory (‘wajeb’) to eat pork at an amountneeded to sustain life.
At any given time, a Muslim may be under morethan one obligation and sometimes these obligations

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are in conflict. There may also be instances when
‘wajeb’ obligations are in conflict with one another. For
example, a Muslim must obey parents and must obey
the religious directions too; what if they are opposite to
one another? The following verses in Quran support
this view:
Quran 9:3: “Allah and his messenger dissolve
obligations.”
Quran 66:2: “Allah has already sanctioned for you
the dissolution of your vows.”
That is why in difficult situations, a Muslim may ask
for a ‘decree’ to resolve such conflicts. What a Muslim
should do depends on the relative importance ofvarious obligations on him. Other than duties towards
God which are absolute, most other moral duties are
not absolute, as opposed to the Kantian anddeontological ethics, in general.
The right order of duties as well as any ‘exceptions’can be learned by referring to one’s pure intention(niyyah) or asked from the religious leader. It should not
be forgotten, however, that Quran also strongly values
human life as the following verse shows; though thismay be interpreted by fundamentalist Muslims asapplying only to fellow Muslims:
Quran 5:32: “...We ordained for the children of Israelthat if any one slew a person - unless it be for murderor for spreading mischief in the land - it would be as if
he slew the whole people. And if anyone saved a life, itwould be as if he saved the life of the whole people....”
Inequality of humans in their prescribed
treatment by Muslims: The other significant issue is acontroversy over belief in universal human dignity
versus a higher status for Muslims over non-Muslims.
Quran regards monotheist religions including ‘true’
Christianity and Judaism highly and refers to their texts
with a lot of respect. However, the following verse may
be interpreted differently:
Quran 3:85: “If anyone desires a religion other thanIslam, never will it be accepted of him and in the
Hereafter he will be in the ranks of those who arelosers.”Quran 3- 110: “You [Muslims] are the best ofpeoples ever raised up for mankind; you enjoin AlMa’ruf and forbid Al-Munkar, and you believe in Allah.
And had the people of the Scripture (Jews andChristians) believed, it would have been better forthem; among them are some who have faith, but mostof them are Fasiqun (disobedient to Allah - andrebellious against Allah’s Command).”
Obligations that a Muslim has towards other
Muslims, such as not to lie to them, may not hold asstrongly to non-Muslims, particularly non-monotheists.
It is therefore not easy to make a general statement on
the standpoint of Islam on universal human dignity andhuman rights. To explain this better, it is helpful to notethat a person’s ‘rights’ may be translated into “duties” or“obligations” of others to treat that person in a certain
way. Accordingly, human rights may be looked upon in
the perspective of “duties” of an individual Muslim (orthe Islamic state) towards other individuals, and not the‘rights’ of the people, as in current mainstream schoolsof ethics. Thus, Muslims may not be obliged by thesame duties towards non-Muslims, as they are towards
fellow Muslims. An action that is forbidden (haram)
towards a Muslim may only be “not recommended”(makruh) or may sometimes be acceptable (mobah)
towards a non-Muslim, and an action that is obligatory(wajeb) towards a Muslim may be just “recommended”(mustahab) or sometimes “optional” (mobah) towards a
non-Muslim.
Fundamentalist Islamic ideologies
Based on the belief that Prophet Muhammad andhis earliest followers were implementing true Islam, andany later innovations (bid’a) are wrong, salafism iscommonly associated with a strict literal interpretationof Islam. They ascribe this belief to a hadith from
Prophet Muhammad, which says: “The people of myown generation are the best, then those who comeafter them, and then those of the next generation”.
A salafi can be from any of the four main schools of
Sunni Islam. They usually condemn certain practices ofother Muslims, especially the shi’a, as polytheism(shirk). Still, most salafis would only preach “purist”
Islam and stay away from political activity. Some salafis
have become politically active, and among this lattergroup, a small number have chosen to follow Islamic
Jihadism. They particularly became apparent in 1990s
and are currently fewer than 10 million in number,worldwide. In Pakistan and Afghanistan, salafi schools(madrasa) were financed by Saudi sponsors who
supported the powerful group known as Taliban.
Therefore, even though Afghans and Saudis come fromdifferent schools of Sunni Islam (Hanafi and Hanbali,
respectively), they shared this purist fundamentalist
interpretation of Islam. As a movement, salafis havebeen growing very fast even into European countries.
What distinguishes salafi jihadism from others is theircommitment to jihad with enemies of Islam, particularly
the USA.
Quran 2- 190: “And fight in the Way of Allah those
who fight you, but transgress not the limits. Truly, Allah
likes not the transgressors.”
2- 191: “And kill them wherever you find them, andturn them out from where they have turned you out.
And Fitnah is worse than killing. And fight not with themat Masjid-al-Haram (the sanctuary at Mecca), unlessthey (first) fight you there. But if they attack you, thenkill them. Such is the recompense of the disbelievers.”
2- 192: “But if they cease, then Allah is OftForgiving, Most Merciful.”
2- 193: “And fight them until there is no more Fitnahand (all and every kind of) worship is for Allah (alone).
But if they cease, let there be no transgression except
against oppressors”.
Bruce Livesey estimates that Salafi jihadists
constitute less than 0.5 percent of the world’s 1.9 billion
population of Muslims (i.e., less than 10 million). Evenso, this is still a large number of potential supporters ofterrorism, under the current geopolitical situation in the
Middle East.

Eubios Journal of Asian and International Bioethics 26 (May 2016)
Discussion
During the literature review, five major risk factors
were identified that could be a reason why a strict
Muslim would be at higher risk of resorting to violenceor accepting it as a possible solution in a conflictsituation. These included the issue of suffering and its
source, a belief in predestination (qadar), an emphasis
on intentions rather than actions for morality, prioritizing
obligations to God compared with duties to other people
and the use of prima facie order to loosen some of thelatter duties, and a belief in unequal treatment of
humans based on religious beliefs. These five major
issues were put into debate with our small group ofMuslim men with fundamentalist (salafi) views, anddiscussed to find out if they were pertinent to the issueof violence observed in their experience. Interestingly,
some points were not apparent in the beginning but
later turned out to be acknowledged and/or accepted by
the discussants as a possible risk factor. This impliedthat the issues were not superficial but lied at the baseof an individual’s worldview. The group agreed that a
Muslim may be deceived /brainwashed into actions ofviolence because of strong feelings of loss, injustice
and anger, affliction with poverty, and encouragementby other trusted Muslims who have similar beliefs as
described in the part of findings. Therefore, the groupbelieves that these beliefs work as risk factors inspecific backgrounds. Unfortunately, for those believing
in Islamic fundamentalism (salafi), level of education
may not be such a protective factor as they tend to
focus on Islamic tradition near the time of its origin,rather than more contemporary reforms.
Almost all discussants in our small group offeredboth ‘theoretical’ and ‘practical’ advice on how not to be
deceived into the ‘wrong’ conclusions. For example,
they said that “God would want us to avoid suffering”,
and “Islam was not about austerity but leading amoderate life”. Also, they believed in the “free will of
humans” and therefore they would condemn an“immature belief in predestination”. They mentioned
how their experience of the turmoil in their people
showed them the very high value of protecting human
life, especially of innocent children and civilians. They
also said that “people cannot be judged” by otherpeople for their beliefs as “only God knows the truth” ofwhat they believe in, and hasty judgements arecommonly false. However, they could understand how
some other Muslims could be coerced by emotional
others into the cycle of violence especially if they had
been exposed to violence; they talked about the cycleof violence, of avenging for the deaths, and of gettingused to witnessing violence in their communities.
The author of this paper thus together with thediscussants came to the conclusion that the above
mentioned ideas could be used as “excuses” to justify
violence among a specific but large number of naïve
people who had suffered or had experienced violencein their own life and thus were ready to make such“incorrect” interpretations of Islamic concepts. We all
agreed that the majority of Muslims in the Middle Easteven in conflict ridden regions were tired of violence

105

and would like it to stop. The discussants suggested
that the misguided teachings to the Taliban and similargroups were to blame for such wrong interpretations ofIslam. Having said that, we could also identify what
concepts could be misused to justify violence to a
Muslim who has fallen into the trap and has given
himself as a tool to the wrongful leaders of violent
and/or terrorist organizations.
The next step was to examine what ideas were
especially prone to misuse; here I shall mention themas risk factors. The most significant risk factor forinciting violence appears to be how evil may be
attributed to God because of strong emphasis on
monotheism (tawheed). ISIS which is currently the mostviolent Islamic group active in Syria and Iraq takes its
ideology from Wahhabism which has been describedby its followers as an Islamic “reform movement” torestore “pure monotheistic worship” (tawheed); they
prefer to be called mowahhidun, which is an emphasis
on pure monotheism.
Apparently, by omitting a role for the ‘evil’ andattributing all that happens to God, the approach of aradical believer to world problems is fundamentallychanged. Essentially, a radical Muslim may only see
himself responsible towards God and not to the people,
other than fellow Muslims, anymore. This can be seenin their black and white flag where the phrase“Muhammad Messenger of God” is written upside down
so that the word God (allah) is placed at the top and
Muhammad is placed at the bottom. This particular
positioning of the words in that phrase implies that God
has a unique position and humans, even the prophet,are only below him.
The next significant risk factor is reliance on theright ‘intention’ (niyyah) rather than the right ‘action’.
This causes a radical Muslim not to think critically ofactions he is committing but mainly of the intentions(towards only God and in the hope of approving God’s
authority over all else). So he may harm or kill a person
if his intention is only to follow God and his decrees.
Next, the prima facie order of duties causes anumber of flaws to appear in the morality because it
allows for committing “more important” duties and aloosening of “less important” or less “strategic” ones
especially in times of war and conflict.
The remaining risk factors also play some roles
though it is hard to say if any of them outweighs others.
A lack of belief in universal human dignity and rights
makes this situation worse. Among radical Muslims, theblood of non-Muslims may be considered as ‘mubah’,
implying that their lives are at peril and their properties
and lives can be taken as a Muslim wishes, without
moral sanctions. Among Islamic jihadists, this view of
inequality of humans may be extended to as far asother Muslims who do not show complete loyalty to thegroup and to the religious leader. Meanwhile, whatever
happens is not critically reviewed for learning a lesson
because it happened with the knowledge of God andthus with God’s omnipotence it would be inevitable tohappen, anyway.

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

The discussions, however, pointed to another factor
that has influenced the relatively larger role of Muslims
in “political” violence. With the establishment of atheocratic constitution in the Islamic Republic of Iran in
December 1979, for the first time in modern era thepolitical foundation of a large and strategic country in
the Middle East was tied to religion and political affairs
came under control. Although Iran was a shia country
and furthermore its model of government did not lead tomuch success, it created a lot of interest among Muslim
groups that had claimed a principal role in governance.
The success of the fundamentalist Muslim group of
Taliban in Afghanistan in defeating the opponents andforming a government in 1996 (till December 2001),
was another example of the merging of religion with
politics in the Middle East. The result has been a larger
intrusion into politics by a minority of Islamic
fundamentalists who then use terror tactics to intimidate
the politically secular majority.
References
Abel, Donald C. Fifty readings in philosophy (2nd edition).
Reading 8 and 9: The problem of evil. Pp: 64-85. Mc Graw
Hill, New York, 2004.
Armstrong, Karen. Fields of blood: religion and the history ofviolence. Knopf Toronto, 2014.
Armstrong, Karen. Islam, a short history. Phoenix, 2001.
Armstrong, Karen. Muhammad: A prophet for our time.
HarperOne, 2007.
Aslan, Reza. No god but God, the origins, evolution, andfuture of Islam. Updated edition, Random House, 2011.
Crooke, Alastair. Resistance: The Essence of the Islamist
Revolution. Pluto Press, London, 2009.
Frazer, Egerton. Jihad in the West: The Rise of Militant
Salafism. Cambridge University Press, 2011.
Gartenstein-Ross, Daveed. Lone Wolf Islamic Terrorism:
Abdulhakim Mujahid Muhammad (Carlos Bledsoe) Case
Study, Terrorism and Political Violence, 26 (1):110-128,
2014.
Henslin, James M. 2009. Terrorism and the mind of God. Pp:th529 in “Sociology, a down-to-earth approach”. 10 Edition.
Boston: Pearson.
Jones, Seth G. 2014. A Persistent Threat, The Evolution ofal Qa’ida and Other Salafi Jihadists. Rand Corporation.
Retrieved 20 Nov 2015. https://www.rand.org/
Sachedina, Abdulaziz. Islamic biomedical ethics, principles
and applications. Oxford, 2009.
Turner, John. From Cottage Industry to International
Organisation: The Evolution of Salafi-Jihadism and theEmergence of the Al Qaeda Ideology. Terrorism andPolitical Violence 22(4): 541-558, 2010.
Turner, John. Religious Ideology and the Roots of the Global
Jihad: Salafi Jihadism and International Order. Springer,
2014.

Hospital food Manipulator’sMoral Judgment Evaluationof Hand Wash TechniqueTraining
1, 3- QCB Marcela Mas-Treviño Dr. Pedro César Cantú2, 3
1
Martínez
MSP César Eduardo Luna-Gurrola
1
Universidad Autónoma de Nuevo León, Facultad deMedicina (Monterrey, N.L., México)
2
Universidad Autónoma de Nuevo León, Facultad deCiencias Biológicas (San Nicolás de los Garza, N.L., México)3
Instituto de Investigaciones en Bioética (Monterrey, N.L.,
México)Email: marce_mastrevino@yahoo.com.mx;
pedro.cantum@uanl.mx

Abstract
Objective: Evaluate moral judgment of hospital foodmanipulators, in training of the hygienic hand wash.
Variables: previous and later moral and social
developments, age, gender, scholarship, and seniority.
Methodology:Anobservational,
longitudinal,
comparative and prospective, non-probabilistic survey,
was executed upon 17, third level attention hospital
food manipulators in Monterrey, N. L. Including women,
aged 18 to 60, attending a three session course withbioethical contents, with an emphasis in hygienic handwash process, with a total of six hours (required
attendance: ≥ 2 sessions).
Background: Moral judgment (Kohlberg), allows
human beings to discern between good and bad, andalso organize life in an intended way, because with histhoughts foretells and impacts not only the decision
making in the working area, but also other aspects inlife. Moral dilemmas, dialogue, and reflection candevelop Moral Judgment.
Legal and moral standards are linked as aconstitutional value that promotes the proxy andrecovery of health in people. Health institutions, as
ethical entities, are responsible for broadening the
ethical professional conscience of their personnel when
promoting courses with a bioethical sense. A course
was chosen for this purpose, oriented to kitchen area
professionals, reminding them about responsibility inhygienic hand washing, the awareness over foodpreparation, storage, and service to prevent food-borne
infections, as a principle of justice for hospitalized
patients. Justice and responsibility, considered as themost important biomedical principles of Beauchamp
and Childress, and care ethics (Gilligan), are expressedin hygienic hand washing procedures.
Keywords: Moral judgment, hand washing techniques,hospital food manipulators
1. Introduction
In these days of intensive technologicaldevelopment in a globalized world, where the economic
competitiveness has displaced the traditional ethicalvalues, and where it seems that dehumanization is a

Eubios Journal of Asian and International Bioethics 26 (May 2016)
constant factor, it is necessary to make a pause on theway to realize how the individual reacts in order to takeaction on the real nature of the human being: caretaking (Torralba-Roselló, 2000). This care is conceived
as the most basic sense of every living being: selfprotection and the protection of more vulnerable"others", observation that is realized from the optics ofthe Ethics of the Care (Alvarado García, 2004).
Moral development, mainly in educational systems
and the society, also affects decision-making or moral
specific behaviors of the working field, and all otheraspects of life. Decision-making originates fromconscience, and this is a sign of authentic humandignity (Vargas Vargas, 2007). According to Kohlberg’s
explanation, moral judgment is made before the action
is taken, and is the reasoning of the individual, which
determines his conduct when he faces dilemmas that
put the acquired values to a test, on having to choose
between a correct or incorrect action (Zerpa, 2007).
It is significant to know that in the last 40 years,
Adela Cortina has warned about the need to extend theethical professional conscience, limited till then only to
doctors, nurses and researchers, to all personnel thatworks in the sanitary world, as an individual,organization or health institution, for the effect offulfilling the tasks that the society has entrusted them. It
is also worth highlighting the fact that the companies
are now necessarily ethical for being immersed in anenvironment of morality, and these, in turn, can be
driven in a morally correct or incorrect manner (Cortina2002).
In accordance with previous information, thejuridical procedures are constituted in an element ofindispensable and obligatory entail with the norms of
moral character that allow us to observe and certify
how moral social pluralism is assumed, not only as afact, but it raises, in these terms, as a constitutional
value that promotes the procurement and recovery of
the health of the persons, which is supported in aspectsof moral character that are happening in the society
and support a point of convergence for the resolution of
the conflicts that have genesis in this area (Albarellos,
2007).
A hospital, institution or health organization, ofundeniable form, is a company that chases a purpose,
for what it establishes limits that facilitate the obtainingof its objectives, nevertheless, in the same manner, it iswarned that there are procedure requirements that they
regulate actions before an individual especially and thesociety. Under this observation, the food manipulatorsof the hospital area must remain included in the need tobroaden their ethical, judicial and professional
conscience, in agreement with what has been
established by Adela Cortina (Cortina, 2002).
Professionals that work in the health area, with orwithout direct contact with the patient, turn into moral
agents who are obliged to provide a briefing of theiractions and be responsible for the consequences
derived from them, even of the generation of
preventable adverse effects.

107

In a particular manner, the limits established by
Norma
Oficial
Mexicana
NOM-251-SSA1-2009,“Hygiene practices for the processing of foods, drinks
or food supplements”, (Secretaría de Salud-2009),
paragraph 5.14, titled “Training”, regulate that the whole
personnel that operates in the areas of production orfood preparation must be instructed in a constant andpermanent way at least once a year, in the goodpractices of hygiene. This includes, among others,
personal hygiene, correct use of the apparel of work
attire (uniform) and washing of hands (5.14.2).
Therefore the present investigation tries toapproach evaluation of the moral judgment of thehospital food manipulators, in the training of handwashing in a health institution of the third level ofattention in the north of Mexico. Using the point of viewof the Ethics of Care, by means of the conscience andthe compassion towards their kind, from theperspective of the Principlism, where the foodmanipulator takes responsibility for all the decisions
and moral actions of professional order that he/she
executes, and seeks to act fairly and responsibly,
sticking to the institutional values.
2. Approach of the Investigation
According to the results of diverse microbiologicalstudies performed on live surfaces (hands) of the foodmanipulators, and the observed numerical values, one
concludes in general that, most kitchen personnel ofthe third level attention hospital, do not know thehygienic hand washing techniques or lack the discipline
to fulfill it in the critical moments, or probably, is noteven conscious of the transcendency of the practiceand of the impact in the prevention of the food borne
illness (“food borne infection”, or “food borne disease”)
for the goals of public health, and social-economic
progress. The previous agrees with the results obtainedin the recent work of Corrêa and Nunes, who advise on
the lack of this habit, in the personnel of health, tobecome attached to the suggested recommendations
about the hand washing techniques (Corrêa andNunes, 2011).
It is necessary to favor the moral judgment
development, with a wide and substantial backgroundin principlism (beneficence, non maleficence, respect
for autonomy, and justice) between the professional of
the nutrition area in regards to the good practices offood production and the practice of the hygienic hand
wash, adducing that must be the very same institution
the one who offers the educational program.
With this activity, the hospital, as macro exampleof the action of the "benefactor", and immersed in the
ethical-juridical frame, stimulates the development of
the moral judgment among the Nutrition area
personnel, to regenerate the conscience centered in the
procurement of justice in doing good and prevention of
avoiding any harm to the peers, “perfect" duties of any
qualified institution with social responsibility.

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3. Situational Frame
Any individual, has the human and inalienable
right to be provided with innocuous food (FAO/RLC,
2010). The procedure of major risk that favors foodcontamination and the surfaces where these areprepared, is malpractice during the hygienic handwashing, as well as the insufficient follow-up or
scanning supervision of this action, in order for it to be
executed in a suitable manner (Caballero-Torres andLengomín-Fernández, 1998).
The context of food safety requires defining someconcepts of competence in this item. Each and every
single manual procedures that are carried out for the
preparation of the food (manipulation), must be
performed on having to follow the indications and taking
the necessary cautions they should, assuring to avoid
or to provoke damage in the patient’s health (practices
of hygiene and innocuousness). Foods that are servedin fixed or mobile locations go through a mechanicalprocess, which goes from the selection, the wash andthe disinfection, when it is necessary, the chopping andmixing, up to its cooking with boiling and humid heat, or
dry heat (baked), or fried, and the cooling or freezing tobe finally eaten, which is then considered to be a
prepared meal (Secretaría de Salud, NOM-51-SSA12009).
The food prepared or ready to eat, can bearstrange material, harmful substances for the health or
microorganisms that exceed the maximum allowed
values (contamination) (Secretaría de Salud, 2009),
which regulates the Official Mexican Norm NOM-251SSA1-2009, " Hygienic practices for the processing offood, drinks or food supplements", and that isexpressed in the technical criterion of Paragraph 1 of
the microbiological sanitary specifications in food, of theInformative Appendix B of the Official Mexican Norm
NOM-093-SSA1-1994, ¨Goods and services. Practices
of hygiene and health in food preparation that are
offered in fixed establishments¨ (Secretaría de Salud,1994).
Food borne infection can surely originate in any
stage of the manipulation of the food, in one particular
procedure, or even, to come from some different
product, to this type of contamination is known as“crossed” (Secretaria de Salud NOM-251-SSA1-2009).
Finally, the product that generates this kind ofcontamination can be also an inert or inanimate surface(tables, cutting boards, knives, another food, etc.) or
live surface (any body surface, mainly hands)(Secretaria de Salud NOM-093-SSA1-1994).
Diverse governing international organizations
agree on indicating that the most energetic measures
and with major impact in the prevention of Food Born
Transmitted Diseases, FBTD’s in forward, are sanitaryeducation programs that promote the information andthe knowledge, to establish healthy habits that
influence the conduct (moral judgment) of theparticipant, in his/her own healthy benefit and that of
the community, furthermore if it is a question of avulnerable population, as the case of the hospitalized
patients would be.

Federal regulations within the Mexican territory
laws, promote among other things, the actions ofphysical or moral persons in search of justice for all. In
the particular case of the present research, the law:
Norma Oficial Mexicana NOM-251-SSA1-2009 is most
relevant. Hygienic practices for the processing of food,drinks or food supplements, approach the hygienic
procedures for the preparation of food, drinks or foodsupplements that are manufactured, served or sold in
fixed establishments, such as the case of a third level
attention hospital and go over aspects as wide as thosethat are elicited in the general regulations: facilities andareas, equipment and tools, services, storage, control
of operations, control of raw materials, control ofpackaging, control of the water that comes in contact
with the food, maintenance and cleanliness, control ofplagues, managing residue, health and hygiene of thepersonnel, transport and training.
Within the general regulations, the NOM-251SSA1-2009 previously specified, a special indication ismade in Paragraph 5.14 defined as "Training" where
directives are urged to give the instruction to the whole
personnel that works in the production and elaboration
areas, with at least an annual frequency, and that itshould include, among other topics, the personal
hygiene, the use of proper gown or uniform for workand the practice of hand washing.
The fact that the health institution adopts asanitary education program for food manipulators, is torespect a juridical federal obligation, but shall aim to go
beyond the elementary mission of satisfying arequirement only for “the duty for abidance". The
hospital, in its position of ethical entity as anorganization or health attorney, can promote among thepersonnel the performance of their work, more than forjust mere abidance, for absolute conviction, where thesearch for the necessary tools to favor the developmentof the moral conscience of the participants is
performed.
The kitchen personnel of the hospital in study,
complies with a performance of 52,800 meals a year,
distributed in three shifts. By considering that every
meal represents a possibility or risk of acquiring a
FBTD, the moral responsibility this represents, for the
Nutrition Service and for the institution, takes them tounderstand the importance of having properly updated
and trained personnel in procedures of correct foodmanipulation and rigorous practice of proper handwash.
This act becomes more relevant, when the
diffusion of knowledge goes hand-in-hand with the"construction" of the reasoning of moral judgment in thefood manipulator, which will allow him/her to act for thehighest well-being (beneficence), with the necessary
diligence to avoid damaging (non-maleficence) in thevulnerable subject, but especially, because they havefull conscience of the sense of justice that every humanbeing rightfully demands, especially the hospitalized
patient, for whom all the efforts are directed.

Eubios Journal of Asian and International Bioethics 26 (May 2016)
4. Referential Frame
4.1 Ethics of care
Humans, just like other living beings, have aprimitive attitude that has been useful to them forsurvive: self-protection and care for their more fragile.
This attitude triggers in humans a series of
responsibilities, and its highest purpose is to achievecare for their peers, or even their own self (Alvarado
García, 2004). The basic elements to execute theaction of “caring”, are clung on a structure moved bycompassion, competition, confidentiality, trust andconscience, are so, the roots of the ethics of care
(Torralba-Roselló, 2000).
The elementary virtues that constitute the ethics ofthe care are explained further where, though both ofthem are important and necessary, its harmonic andthorough amalgam is required to obtain the best results.
A) To perceive the vulnerability of an individual, and to
be sensitized in a conscious way before the suffering ofanother, is what gives origin to the virtue of pity orcompassion. B) The development of the professional
activity, across knowledge, the techniques, the skills
and the procedures, lead to the domain and suitableapplication of them, which is considered ascompetence in an individual. c) Confidentiality is
explained as the capacity that an individual possesses
to be a silent depository of the secrets and intimate lifeof another subject. D) The certainty in something or insomeone generates the confidence and provokes thetranquility to what the person is recognized by moral or
professional authority, as well as in the actions that are
executed. E) An internal resource of the human beingthat is basic for the good professional practice is thevirtue of conscience, which leads the individual to own
knowledge and its prudential use, by deduction of theconsequences that are obtained in means of thepractice of reflection (Torralba-Roselló, 2000).
With the passing of the years, the amazing
technological and scientific advances, as well as theglobalization, have generated a transformation in theculture of the human beings, leaving aside the human
traditional values, being substituted or replaced for"having ", with a repercussion in the individual andsocial conduct (Franco and Velazquez, 2007). This newstate of mind has brought as a consequence thedehumanization: the people already do not look for thecommon well-being, but only the individual or own. The
society and organizations have become egocentric. It ishere where ethics of care rises on a counter-flow, by
trying to understand the world in which it is immersed
and in which the human being operates, to be able tounderstand and rescue the most basic attitude which isthe commitment and responsibility towards “the other”,
and where this link is expected to translate into actionsof aid and help towards others.
The concept of ethics of care differs from themodel of principlism in ethics developed by
Beauchamp, T. L. and J. F. Childress (1979), which isbased in four universal principles of bioethics:
autonomy, beneficence, non-maleficence and justice.

109

4.2 Principlism
During the 1980s, the book Principles ofBiomedical Ethics published, from the authors Tom L.
Beauchamp and James F. Childress, proposed a newconception in ethics, which serves as a moral
archetype for the workers of the health sector, with the
purpose of clarifying their doing upon concrete andparticular situations; these are four principles that serve
as support to this new philosophic current: autonomy,
beneficence, non-maleficence, and justice. These
principles, according to what was mentioned by theauthors, constitute the universal norms of common
morale and are present in all individuals (Beauchamp
and Childress, 2009).
These principles lack a hierarchic value per se, so
that, in conflicts or complicated dilemmas, specifically
medical bioethics, favors the convergence in a solution,
suitably among the different parts involved, even if theparticipants or contenders, differ in their ethicaltheories. It is sure that the resolution would not be
simple because the moral acts possess the same value
and the reasons will never be conclusive.
The principles of this philosophical current arecompatible with different theories and are explained ordefined as follows: a) The inherent dignity of every
subject allows every individual to have advantage tomake more suitable decisions according to their values,
criteria or preferences, in such a way that the persons
with their right to their autonomy, decide on their own;
but also establishes that an individual with diminishedautonomy, has a right for protection. This value isintimately related to the so-called informed assent. The
person or to the patient is recognized as the main
character, which brought a radical change in the, tillthen, paternalistic existing ethics, since it suggests a
moral limit in the intervention of the doctor. b) Doing
always the good upon someone defines the principle ofbeneficence, and this has been by excellence theregulatory engine of the relation doctor - patient. The
inconvenience arises in the precise moment in which
an interpretive arrangement of what is understood as“good” has to be reached. c) Priority principle, primun
non nocere, is an obligation of all individuals not tocause meaningful harm or damage to any other person,
this is how non-maleficence is defined. This principle
belongs to the oldest tradition of medical ethics and it ismentioned in the Hippocratic Oath; it relies on theactions of the doctor. d) The principle of justice not
only includes the patient and the doctor, but it includes
the participation of the society as well. Suppose aregulation to the distribution of health resources. Eachindividual has a right to be respected and treated fairly
and equally, without distinctions. Similar as theinalienable right to live, we have the right to receive
sanitary attention. For this particular case, thedistribution of goods also includes organizations,
hospitals, or research centers whose work is related tohealth (Institut Borja de Biotica, 2011; Lacalle, 2014).

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

4.3 Moral judgment theory development
An outstanding topic within behavioral science ismoral development, mainly within educational systems
and society, though it is undeniable that it also affects
the decisions making or moral specific behaviors of thework area, and in any other aspect of life.
Lawrence Kohlberg is probably the most quoted
exponent in Psychology and Education, with the topic of
the theory of the development of the moral judgment,
which explains actions of the individual in life,
especially when they put dilemmas about acquired
values to a test by having to choose between a correct
or incorrect action. For Kohlberg it is in this precise
moment when the moral judgment is given form. The
dilemma arises because of the cognitive imbalance that
supposes the confrontation of two values before an
experience, but once the problem is confronted, and thesolution is constructed, by observing the values, thethought restores its balance (Zerpa, 2007). It is moral
judgment that allows the human being to organize
his/her life in an intentional way, because with thethought foresees his/her real motives to act and has theability to construct strategies of action.
In order for an individual to make moral judgments,
he/she must transit though a stratified progression of
their own sense of justice, along with the type of
reasoning that is used; in agreement with this, Kohlberg
suggests a "cognitive - evolutionary" theory of thedevelopment of moral judgment, where the person, in
addition to internalizing the social rules, builds new
forms of thought that allow him/her to be mobilized by
freedom in his/her environment. The logical reasoning
always will be prior to the moral reasoning; anindividual could be placed in a high level of logicalreasoning, even higher to the level of the moral
reasoning, but this could not happen the other way
around (Monsoon, Monsoon, Ariasgago and Rauch,2006).
The moral judgment of the human being evolves
from the primitive egocentric stage, up to a condition
evolved with a social holistic vision and has to thejustice as maximum value, which allows to theindividual to discern between (among) the good thing or
the just of a fact. Kohlberg makes clear that the moral
development happens during the whole life of theindividual, as it is the case. The conduct of an individualis governed by his (her, your) thought or the reasoningthat it (he, she) realizes (Suárez and Rocks, 2006).
Kohlberg's theory raises the existence of threeconstant levels of development of reasoning or moral
conscience, each conformed, by two steps or stages:
pre-conventional, conventional and post-conventional.
Every step and every stage represents a hierarchic
integration, they are considered as epigenetic, they
have a unique way of interpreting and understanding
the social / moral order, where the post-conventional
level is the highest (Narváez, 2003). In addition, stages
have the characteristic of being cognitive, formal anduniversal.
Recently, Zerpa and Ramirez published the work
“Morality, empathy, emotional intelligence andtransformational leadership: a model of routes instudents of MBA programs in a Venezuelan university”,
where they use and make reference to the theoreticalmodel of the development of Kohlberg's moral
judgment (1969, 1992), that is outlined as follows(Zerpa and Ramirez, 2013):
a. Pre-conventional level
The individual neither understands nor defines therules. And has an individual perspective. This responds
to the cultural patterns and the example. The "right"
and the “wrong" is recognized as a result for obtaining a
reward, punishment or exchange of favors.
Stage I: Punishment and obedience, it orientates theobedience to avoid the punishment.
Stage II: Instrumental exchange, where the rules arerespected by convenience.
b. Conventional level
The individual surrenders to the rules, expectations, orthe authority. Conscience is held over what society
demands and what judges as right or wrong. In thislevel, it is important to be sought as "good" by others.
Stage III: Interpersonal (tribal) conformity. Individual
acts to gain approval of others.
Stage IV: Social system and conscience moral.
Respect for fixed rules, law and constituted authority.
Responsibility toward the welfare of others in society.
c. Post-conventional level
The rights, values, or principles approved by themembers of society, pave the way to moral decisions.
Resolution to social-interest based conflicts are sought,
not the individual interest.
Stage V: Prior rights and social contracts. Justice
distributed proportionate to circumstances and need.
“Situation ethics”.
Stage VI: Universal ethical principles. Recognition of
the moral universal principles with sustenance in ethics
and justice, yet over social laws.
Therefore, Kohlberg's steps or stages, describe
how the individuals construct their moral judgments,
and are strongly related with the social development
and moral reasoning that they have achieved.
4.4 Food manipulators
Every person who executes manual operations
during any of the processes of food preparation isconsidered to be a manipulator in agreement with theSecretary of Health in Mexico (NOM-251-SSA1-2009).
Being the hands of the manipulator the principal sourceof contamination, (Generalitat Valenciana, Conselleríade Sanitat, 2001), (FAO, 2009) and the most importantwork tool that the one who elaborates the foodpossesses, since with hands one selects, prepares andmixes ingredients to achieve an agreeable dish to sightand exquisite to the palate, although pathogenic germs
can also be transmitted with them (coming fromintestine or wounds, and from the manipulation of raw
meats or other food), through direct or indirect contact

Eubios Journal of Asian and International Bioethics 26 (May 2016)
with surfaces, causers of the so called food borne
transmitted diseases (Pantoja, 2010).
When the kitchen worker evolves in anenvironment where the interior analysis of theprinciplism in bioethics is promoted, under theobservance of the ethics of care, the worker observes,
thinks and acts in consequence; to rescue the basic
virtues of taking care of the vulnerable subject. It isthrough cognitive and moral reasoning that they allow
themselves to build new structures, coming from theirinteraction with the environment. It is through their
cognitive - moral reasoning what allows them toconstruct new structures from their interaction with theenvironment and to anticipate action with will andconviction, and manages to establish a soldierycommitment to help, which can be called a "social
responsibility”.
5. Methodology
The current prospective study of observational
character, longitudinal and comparative, was performed
in March 2015 in a third level attention health institution
in Monterrey, Mexico. Where 17 female foodmanipulators, who willingly accepted in agreement withthe consent format suggested by the General Health
Law (Ley General de Salud). The development of moral
judgment was evaluated using a “Defining Issues Test”,
where 6 dilemmas were included, with a Chronbach’s
alpha of 0.71, which was applied before and after a 3
session course with bioethical contents for foodmanipulators, with an emphasis in hygienic hand wash.
Such a course is completed in a total of six hours of
training, and also included aspects related withpersonal hygiene, proper use of work attire (uniform),and hand wash, real dilemmas or moral hypothetical
discussions were used, as well as dialogue andunderstanding, activities suggested by Kohlberg’s
theory. The variables were registered for post analysis
using SPSS program.
6. Results
The population of this study was conformed byfemale participants. With an average age of 46.4 years,
with a data variation of 10.95 years of age with regard
to the average opposing value. The youngest was 21
and the oldest was 59 years old. The time thispopulation had been working in this institution reported
an average of 8.5 years with a data variation withregard to the average opposing value of 8.34 years ofstay. The shortest time reported was a 0.6 years of stayand the maximum of 34 years in this position.
Regarding their academic level, 58.8% haveattended or completed secondary or junior high school,
17.6% received accredited training as a technician inthis field, and 5.9 % show evidence of high schoolstudies. The population without any professional
studies are a total of 82.4%, where 11.8% haveaccreditation of nurse licensing and 5.9% in
gastronomy. Currently 94% declared that they are notstudying at the moment of this training course, where
as only 6% are formally registered in an educational111

institution, taking a course in the marketing area. They
were also questioned about having an additional job,and 94% answered they had no other work, while 6%
have another type of work activity. In regards to theirreligious practice, 71% stated they do not follow any
cult or religion, where 29% do, and from these, 82%
claimed to be Protestants and only 17% are Catholic.
In relation with the development Levels of Moral
Judgment that prevail in the pre and post intervention,
we find that those who prevail in level 4, which relates
to the relations, expectations, mutual interpretations
and interpersonal conformity. On having preinterventions value of 4.593±1.114 and postintervention of 5.801±1.407; that in addition turned out
to be statistically significant difference when comparing
them shows 95% reliability (value of P 0.043). It was
not quite this way in other levels. With reference to the
P index that details the morality of principles, this does
not show significant difference in its measurement
values.
7. Discussion and Conclusions
The results obtained in the present researchcorrespond to a study that intended to determine if acourse about food manipulators, with bioethicalcontents, could achieve a change in the development of
the moral judgment in personnel of a third level
attention health institution. The course was carried out
with the intention of influencing the development of themoral judgment, which is given thanks to thetransformations of the cognitive organization, by which
it is assumed that the claimed change is a process inascending order, destined to obtain levels of majorbalance, which is not possible to foretell only by thelearning, but through the education of the moral
development of the participants, where humancharacter decisions are truly made (Aguirre Dávila,2009).
The resulting significant changes in theparticipants of this research correspond to theconventional grade in level 4, which has an orientation
toward keeping social order. Nevertheless, having
found a significant difference, these results did notconclude any change regarding moral developmentlevel. However, we can infer that among theparticipants, hospital food manipulators, their biggest
concern lies among the constitution of a good employee
in the health area, who from within a wider referential
frame, could project him/herself over the social
relationships possessed, where the priority is to comply
or fulfill the regulatory aspects of their assigned chores
with the purpose of maintaining an order and a goodworking environment.
In this respect, the supreme reason is to make asocio-labor conscience prevail, which demands people
fulfill their work obligations with society, and only inextreme situations they would not follow a regulatory
indication, and if this were to happen, they would
always be in the condition in which another social dutywith higher relevance is fulfilled. This situation reveals amoral sensibility with an orientation of inner-lying

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

character that is reflected upon the attitude of theparticipants in this investigation, since with this thecooperation among the members of a society, of agroup or of an institution, is manifested (Vargas Vargas,2008). Particularly, the situational context of the present
research is to contribute to the health rehabilitation of
the persons who receive their services, in order to fulfill
the inscribed goals of justice and responsibility inimplementing bioethics principles as well as in the
ethics of the care.
8. References
Aguirre Dávila, E. (2009). Aproximación pragmática a lateoría del juicio moral, desde la crítica a Kohlberg.
Rev.latinoam.cienc.soc.niñez juv, 7 (2), 1273-1299.
Albarellos, L.A. (2007) Bioética con trazos jurídicos. México.
Editorial Porrúa.
Alvarado García, A. (2004). La ética del cuidado. Aquichan, 4(4), 30-39.
Beauchamp, T. L. & Childress, J. F. (2009). Principles ofBiomedical Ethics. New York City. Oxford University Press.
Caballero-Torres, Á., & Lengomín-Fernández, M. E. (1998).
Causas más frecuentes de problemas sanitarios enalimentos. Rev Cubana Aliment Nutr, 12 (1), 20-23.
Chávez de la Peña, M.A. et al. (2001). Brote por Salmonella
enteritidis en trabajadores de un hospital. Salud Pública deMéxico, 43 (3), 211-216.
Corrêa, I. & Nunez, IMM. (2011). Higienización de las manos.
El cotidiano del profesional de la salud en una unidad deinternación pediátrica. Invest Educ Enferm. 29(1):54-60.
Cortina, A. (2002). La ética de las organizaciones sanitarias.
Revista Gerencia y Políticas de Salud, 1 (3), 6-14.
FAO/RLC (2010). Foro Regional Políticas de Seguridad e
Inocuidad y Calidad Alimentaria: Casos Exitosos deIntegración. Santiago de Chile. FAO/RLC.
FAO (2009). Manual Comunitario de Higiene e Inocuidad delos Alimentos. Proyecto Educación Alimentaria y Nutricionalen escuelas de Educación Básica. Santo Domingo. FAO.
Franco Peláez, Z.R., & Velásquez Giraldo, C.A. (2007).
Desarrollo humano y ética del cuidado en el mundo
globalizado y fragmentado de hoy. rev eleuthera, 1, 141-163
Generalitat Valenciana, Consellería de Sanitat. Dirección
General para la Salud Pública (2001). Manual Guía delmanipulador de alimentos. Valencia. Generalitat Valenciana,
Consellería de Sanitat. Dirección General para la Salud
Pública.
Institut Borja de Bioètica (2011). Principios de Ética
Biomédica, de Tom L. Beauchamp y James F. Childress.
Bioètica & Debat 17(64): 2
Lacalle Noriega, M. (2014). La persona como sujeto dederecho. Capítulo 9 Personas y Bioética. (144-145). Madrid,
España: Editorial Dykinson, S.L.
Monzón, J.E, Monzón, W.A., Ariasgago, O.L., Rauch, E.
(2006). Análisis comparativo del Test de Rest (DIT) para su
aplicación en el ámbito de la UNNE. Universidad Nacionaldel Nordeste. Comunicaciones Científicas y Tecnológicas.
Narváez, D., (2003). Educación y desarrollo moral. Acta
Republicana Política y Sociedad, 2 (2). 39-49.
Pantoja Ludueña, M. (2010). Higiene de manos y riesgo deinfecciones. Editorial Rev Soc Bol Ped, 49 (2) 83-84
Secretaría de Salud. (1994). Norma Oficial Mexicana NOM093-SSA1-1994, Bienes y servicios. Prácticas de higiene ysanidad en la preparación de alimentos que se ofrecen enestablecimientos fijos. Publicada el 29 de julio de 1994 en el
Diario Oficial de la Federación

Secretaría de Salud. (2009). Norma Oficial Mexicana NOM251-SSA1-2009. Prácticas de higiene para el proceso dealimentos, bebidas o suplementos alimenticios. Publicada el
10 de octubre de 2008 en el Diario Oficial de la Federación
Suárez Medina, G.A., Meza Rueda, J.L. (2006). Conciencia
moral. Estudio del desarrollo de la conciencia moral y
propuesta para su formación en la Educación Superior.
Revista de Investigación 6(1), 131-139
Torralba-Roselló, F. (2000). Constructos éticos del cuidar.
Paper presented at the XXVI Congreso Nacional de la
SEEIUC, Barcelona.
Vargas Vargas, J.E. (2008). La formación de la conciencia
moral en la Universidad Militar Nueva Granada. Revista
Latinoamericana de Bioética, 8 (1), 76-87
Zerpa, C.E. (2007). Tres teorías del desarrollo del juicio
moral: Kohlberg, Rest, Lind. Implicaciones para laFormación moral. Laurus, Revista de Educación 13(23),137-157.
Zerpa, C.E., & Ramírez, J.J. (2013). Moralidad, empatía,
inteligencia emocional y liderazgo transformacional: un
modelo de rutas en estudiantes de posgrado gerenciales enunauniversidad
venezolana.
Revista
Diversitas.
Perspectivas en psicología 9 (1),109-126.

Student Perceptions andAttitude towards Bioethics
Teaching to Undergraduate
Medical Students- Zoheb Rafique, MBBS, MBIOETH
Lecturer, Department of Community Medicine,
Liaquat University of Medical & Health Sciences (LUMHS),
Jamshoro, Pakistan
Email: dr_zohaib@hotmail.com

Abstract
Bioethics is being taught nowadays all over theworld to improve student’s understanding of ethicalissues in contemporary medicine. Undergraduate aswell as postgraduate students are being trained inbiomedical ethics to recognize and identify ethicaldilemmas and then resolve them and also to face thesituations where there is need of ethical analysis. This
study was conducted at a medical university to assess
the attitude and perception of undergraduate medical
students regarding their bioethics curriculum, course
contents and understanding of ethical issues. A total of
280 students responded to the questionnaire to assess
their attitudes. This study was conducted in April 2015
and it reflected that students are aware about ethicalissues in their field and they have reasonable
understanding of their curriculum and course contents.
Keywords: Attitude, Perception, Bioethics, Teaching
Introduction
Bioethics has evolved over the last four decades,
predominantly in the western world and then spreading
its domain worldwide. It is being taught to enhance theunderstandingofdifferent
ethicalissuesinEubios Journal of Asian and International Bioethics 26 (May 2016)
1

contemporary medicine . In Pakistan, it was started at
2
Agha Khan University (AKU) in 1997 and now it isbeing taught all over the country. It was started at ouruniversity Liaquat University of Medical and Heath
Sciences (LUMHS) in 2007 and it primarily involved
undergraduate MBBS students. Unlike previously,
nowadays graduating doctors of many medical
institutes of Pakistan are familiar with terminologies likeconfidentiality, informed consent and conflict of interest.
Regular seminars, symposiums and workshops arebeing conducted allover the country about theawareness of bioethics. Publications from Pakistan on
ethical problems are often seen on both national as wellas international forums. Ethical review committees are
now an important part of teaching hospitals and aremandatory
requirementfor
any
substantial
accreditation. Funding agencies are aware of thenecessity of ethics and require that the ethical issues
must be properly addressed for all research work
including clinical or laboratory research work, prior to3.
commencement Medical educators have focused on
the necessity of including bioethics in medical school
curriculum. They suggest that biomedical ethics
education can contribute significantly to thedevelopment of "physicians' values, interpersonal skills
4and social perspectives for the practice of medicine .
Knowledge of biomedical ethics and moral reasoning
are essential to good patient care and is same just as
biomedical knowledge and technology are to diagnosis
and the management of disease. Allover the world, theteaching of medical ethics in health sciences have been
subjected to clinical and scientific teaching. In 1999,
World
Medical
Associationhas‘‘strongly
recommended’’ to medical institutes all over the worldthat the teaching of medical ethics and also the human5.
rights should be made compulsory in their curricula In
our university Liaquat University of Medical and Health
Sciences (LUMHS) bioethics is being taught in allundergraduate programs and all essential topics arecovered in the curriculum. This article reports theexperience of evaluating the undergraduate bioethics
curriculum in relation to students’ attitude andperception of teaching of biomedical ethics andunderstanding of ethical issues.
Material and Methods: To assess the perception andattitude of undergraduate medical students at LUMHS
Jamshoro regarding bioethics curriculum and ethicalissues, a self report structured questionnaire wasrddesigned. The study population included the 3 year
MBBS students. A total of 280 students participated inthis study and 27 students didn’t returned thequestionnaire and 46 students were absent. There are
353 students enrolled in this batch. The questionnaire
was distributed among the students at the end of theirbiochemistry practical classes. It took six working days
to complete this study. It was conducted in April 2015.
The students took 15 to 20 minutes to fill thequestionnaire. All the students willingly consented andparticipated in this study. The questionnaire used in this113

paper consisted of total 32 questions and it was
structured according to the course contents.
Results
A total number of 280 Undergraduate MBBS
Students participated in this study. There were 127
males and 153 females. Table 1 shows the responsesof the students to the questionnaire.
Table: 1 Attitude and perception of undergraduate
students on bioethics curriculum and ethicalissuesStatement Responses
Do You Know?
Yes (%)
1. Why we need bioethics?
221 (79%)
2. What are fundamental principles of bioethics?
230 (82%)
3. What are components of medical ethics?
193 (69%)
4.
What are different types of physician-patient
relationships?
207 (74%)
5. What are the issues of organ donation?
191 (68%)
6. What is euthanasia?
202 (72%)
7. What are different types of euthanasia? 201 (72%)
8. What is privacy?
196 (70%)
9. What are different types of privacy?
188 (67%)
10. What is veracity?
187 (67%)
11. What is fidelity?
185 (66%)
12. What is an ethical dilemma?
198 (71%)
13. What are the steps required to resolve an ethicaldilemma?
190 (68%)
14. Why medical representatives of pharmaceuticals
companies offer promotional gifts tophysicians/doctors?
224 (80%)
15. It is unethical for physicians/doctors to accept
promotional gifts and perks from pharmaceuticalcompanies?
232 (83%)
16. What is medical error?
235 (84%)
17. How to avoid medical error?
232 (83%)
18. What are types of errors?
229 (82%)
19. What is professional ethics?
218 (78%)
20. What is the dual role of doctor as physician andinvestigator?
210 (75%)
21. What are the points of Nuremberg code?185 (66%)
22. What are different ethical theories?
202 (72%)
23. What is informed consent?
244 (87%)
24. What are the components of informed consent?
241 (86%)
25. What is difference between verbal and writtenconsent?
244 (87%)
26. What is confidentiality?
207 (74%)
27. What are the exceptions to the requirement ofconfidentiality?
201 (72%)
28. What is the importance of confidentiality in medical
research?
185 (66%)
29. What are the circumstances in which confidentiality
can be breached?
201 (72%)
30. What is bad news?
199 (71%)

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

31. What is ABCDE pneumonic for breaking bad news?
191 (68%)
32. What are the things to be avoided while breaking
bad news to the patient or his/her family? 188 (67%)
Discussion
This study was conducted to assess theperception of undergraduate medical students
regarding their bioethics curriculum, course contents
and different ethical issues and dilemmas which they
will face in their future practices. The curriculum at ouruniversity is very diverse and it covers all major areas
related to medical ethics and it is reflected in thequestionnaire also. It covers informed consent alongwith its components, fundamental principles of bioethics
and their application, privacy, veracity, fidelity andconfidentiality in detail. It also covers areas like organ
donation and ethical issued related to it, euthanasia
and its types, medical error and ways of preventing it,
professional ethics, Nuremberg code, ethical dilemmaand steps to resolve dilemmas. The course contents
also include relationship between doctor and patient,
between doctor and representatives of drug companies,
breaking bad news and things to be avoided while
breaking bad news. Theories of bioethics are also
covered in it with pros and cons of Utilitarianism,
Kantianism,
Liberalindividualism
andCommunitarianism. Bioethics teaches us what ought tobe done at difficult situations and sometimes thetheories and principles nullify each other, but we haveto take good things from each theory and also fromfundamental principles.
rd
The present study was conducted on 3 year
medical (MBBS) students due to the fact that bioethics
is being taught in the initial two years of their courseand from third year onwards the students have clinicaland ward rotations. The students are fully aware of thissituation and they can relate bioethics in ward postingsand it starts from history taking and general physicalexamination of the patients in third year MBBS. A good
doctor is not only ethically well behaved but istechnically sound also. Medical practice is an
intrinsically ethical enterprise because of the reason
that patients are vulnerable and medical treatments are
not only technical, they often invade the bodies of6.
patients and often engage their consciences The
results of present study indicate that majority ofstudents do have awareness about bioethics and they
can understand the ethical issues. The questionnaire
was designed while keeping in mind the course
contents. The response of the students shows that 66
to 87 % students agreed to the statements and said yes
in different questions. When asked about the need ofbioethics and fundamental principles, 79% and 82%
students said yes to both questions respectively. Thisshows that they know why we need bioethics and how
we can apply and learn fundamental principles.
Bioethics is taught at our university in lecture format
and it is included in the final semester exams and themarks are included in final assessment and theattendance also counts. The students were asked

about euthanasia and its types, and in reply 72% of thestudents agreed with yes. The questions related to
ethical dilemma were also asked and the students
replied with yes 71 and 68% and it implied that they doknow what is ethical dilemma and what are the steps
involved in resolving them. In majority of questions
students replied with yes and with approximately 70%
positive responses. When asked about medical error,
its avoidance and types, 82 to 84% students repliedwith yes. The results also indicate that students areaware of secondary principles and rules of bioethics
like confidentiality, fidelity, privacy and veracity. They
are aware of promotional gifts given by medical
representatives and the motive behind them. The
students were also asked about professional ethics anddual role of physician and investigator and they repliedwith yes with percentages of 78 and 75% respectively.
The students also knows the process, definition andpneumonic of breaking bad news and also the things to
be avoided while breaking bad news to the patient.
They replied with 67 to 71% respectively. The mostimportant topic of bioethics is informed consent andwhen the students were asked about informed consent,
its components and difference between verbal andwritten consent, the students replied with 86 to 87%
yes. The present study shows that students are aware
about their bioethics course and they are now able toidentify and resolve ethical conflicts and dilemmas.
Conclusion
This survey was done to assess theunderstanding of undergraduate medical students
regarding ethical issues in contemporary medicine andalso their bioethics curriculum. The bioethics curriculum
is recognized and designed by both Higher Education
Commission (HEC) Pakistan and Pakistan Medical and
Dental Council (PMDC). This study will help us in the
future to fill the gaps in bioethics teaching, curriculum
design and in improving student learning of ethicalissues.
References
1. Zoheb Rafique. Bioethics Teaching and Assessment: My
Experience of Three Institutes. Bangladesh Journal of
Bioethics 2014; 5(2):44-48.
2. Rubina Naqvi. Teaching Bioethics to Medical Technology
Students in Pakistan. Journal of Medical Ethics andHistory of Medicine 2009, 2:8.
3. Muhammad Shahid Shamim and Muhammad Shahzad
Shamim. Medical Ethics: A slow but sustained revolution
in Pakistan’s healthcare. J Pak Med Assoc 2010; Vol. 60,
No. 9, 706-707.
4. James W Tysinger Et Al. Teaching ethics using smallgroup, problem-based learning. Journal of Medical Ethics
1997; 23: 315-318.
5. Keymanthri Moodley. Teaching medical ethics toundergraduate students in postapartheid South Africa,
2003–2006. J Med Ethics 2007; 33:673–677.
6. KULSOOM GHIAS Et Al. How we developed a bioethics
theme in an undergraduate medical curriculum. Medical
Teacher 2011; 33: 974–977.

Eubios Journal of Asian and International Bioethics 26 (May 2016)

Perception of Nursing
Ethics among
Undergraduate Nursing
Students at a Nursing
Institute of Pakistan- Zoheb Rafique, MBBS, MBIOETH
Lecturer, Department of Community Medicine,
Liaquat University of Medical & Health Sciences (LUMHS),
Jamshoro, Pakistan
Email: dr_zohaib@hotmail.com

Abstract
Objective: To evaluate the perception of nursing ethics
among undergraduate nursing students and to explore
their understanding of nursing curriculum and ethicalissues in the field of nursing.
Materials and Methods: The final year nursing
students at nursing school LUMHS were given the predesigned self report questionnaire and they wererequested to take part in this study.
Results: Forty present students took part in this study
and 8 students were absent. The students acceptedthat learning nursing ethics is very essential tounderstand their responsibilities which they havetowards their patients and to understand ethicaldecision making. The students were satisfied and foundtheir curriculum comprehensive and good for learning.
Conclusion: The students’ evaluation of nursing ethics
shows that the undergraduate nursing students do haveknowledge about ethical issues in the field of nursing
and they are able to identify and resolve those issues.
They have also good knowledge about their nursing
curriculum and they found their curriculum ideal andcomprehensive.
Introduction
As a result of advances and modernization in scienceand the technology, more ethical issues and dilemmas
occurring in health care have been identified. Generalpublic, health care professionals and policy makers are
more aware of these dilemmas now. In the past years,
nurses were always expected to be obedient and learn
without question and also did not participate in the
ethical decision making. Because of this view towards
nursing, ethics was regarded as the science of conduct
and ethics content of nursing curriculum focused on the
obligations and duties of nurses. However, theincreasing complexity of the health care delivery
system requires increasing responsibility for the ethicaldecision making in the nursing care. In clinical practicenurses can be confronted with the issues related toinitiating resuscitation and discontinuing life saving
treatment or patients refusing treatment (1). Clinicalexperience has always been an essential part ofnursing education. It prepares nurses to be able of"doing" and "knowing" the clinical principles in nursing
practice. The clinical practice encourages students to115

use their abilities and critical thinking skills for the
problem solving (2). Nursing as a practical field,
requires students to develop those clinical skills that arevery essential in caring. The process of clinicalinstruction occurs in different variety of social andcultural contexts and behavior of clinical instructors
plays very important role in learning process of thestudents. Clinical teachers have the opportunity to
influence the students’ learning and these students
eventually graduate and shape their nursing practice(3). Bioethics is being taught at our university Liaquat
University of medical and health sciences (LUMHS) in
all fields and nursing is not the exception. Nursing
ethics is taught in final year of undergraduate nursing
and the students have clinical rotations through out
their undergraduate period. The curriculum isrecognized by Higher Education Commission (HEC)
Pakistan and Pakistan Nursing Council (PNC). In thispaper I will determine the perception of students
regarding their curriculum and also their understandingof the ethical issues and dilemmas in the field ofnursing.
Material & Methods
To determine the perception of undergraduate
nursing students at nursing institute LUMHS Jamshoro
regarding nursing ethics, a self report questionnaire
was designed. The study population included final yearthnursing students (BS Nursing 4 Year). A total of 40
present students took part in this study and 8 students
were absent. There were 48 enrolled undergraduate
students in this batch. The questionnaire wasdistributed among the students on last day of their final
year classes. The data for this paper was collected on
20th February 2015. The students took 15 minutes incompleting the questionnaire. The students consented
and willingly participated in this study. The
questionnaire used in this paper consisted of a total of
12 questions. The knowledge of students was tested
and 5 point Likert scale was used in the questionnaire.
The responses were 1 to 5 as 1 very low; 2 low; 3
moderate; 4 high; 5 very high.
Results
A total number of 40 undergraduate nursing
students participated in the study. The content of
nursing course is shown in Table 1. Table 3 shows the
responses of undergraduate students regarding thequestionnaire. There were 4 male and 36 female
students.
Table 1: Contents of Nursing Ethics Curriculum• Introduction to nursing ethics• Value Set• Ethical principles and theories• Confidentiality and informed consent• Bills of rights• Code of ethics• Nursing practice• Professional autonomy and ethics• International health organizations and nursing
organizations

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

Table 2: Perceptions of nursing students regarding
nursing ethics
Likert Scale: 1 very low; 2 low; 3 moderate; 4 high; 5 very high.

Statement:
How do you rate your knowledge
about:Response:
1 2 3 4 5
1. Main Ethical Theories and Principles(1) 0 (2) 0 (3) 2 (4) 26 (5) 12
2. Key concepts of nursing ethics(1) 0 (2) 0 (3) 4 (4) 25 (5) 11
3. Identify ethical issues and relate it to nursing
practice (1) 0 (2) 0 (3) 6 (4) 20 (5) 14
4. Conflict arising in nursing due to different value
and cultural sytems(1) 0 (2) 0 (3) 5 (4) 21 (5) 14
5. Complete understanding of nursing ethics
curriculum and course contents(1) 0 (2) 0 (3) 3 (4) 27 (5) 10
6. How to apply case based reasoning
inresolving ethical problems(1) 0 (2) 0 (3) 4 (4) 24 (5) 12
7. Ethical issues arising due to organ donation(1) 0 (2) 1 (3) 6 (4) 24 (5) 9
8. Informed consent andits meaning in
healthcare(1) 0 (2) 0 (3) 1 (4) 22 (5) 17
9. Advance directives when patients are
terminally ill(1) 0 (2) 4 (3) 4 (4) 27 (5) 05
10. Brain death diagnosis in the patients(1) 1 (2) 2 (3) 7 (4) 21 (5) 09
11. Understanding Code of Pakistan
Nursing
Council(1) 0 (2) 0 (3) 4 (4) 21 (5) 15
12. The moral and ethical issues arising fromwithholding and withdrawing of life sustaining
treatments(1) 0 (2) 2 (3) 4 (4) 21 (5) 13
DISCUSSION
The challenges faced by nurses in rapidlychanging health care environments have highlighted
the need for graduating nursing students to feel bothcompetent and also prepared for practice. This
importance and necessity has highlighted theincreasing significance of the quality and nature of
student clinical learning experiences (4).
Ethicscurriculum which is being taught at the Nursing Instituteof LUMHS is very comprehensive and covers almost all
the areas of clinical practice. The basic concepts of
ethics, its theory, principles and norms are covered.
The course content comprises of units and divided into
various components.
The first unit which includes introduction tonursing covers definitions of ethics, bioethics, nursing
ethics, moral attitude and ethical dilemma. It also
includes importance of ethics in nursing, review criteriaof a profession and how to develop characteristics of aprofessional nurse. The second unit includes value set
which comprises of identification of personal, societal,organizational, professional and moral values. It further

focuses on recognition of value conflicts and implication
to nursing practice, how to develop professional values
and implication of nursing care ethics in society. The
third unit includes ethical theories and principles andincludes ethical principles in health care in the light of
ethical theories. It further discusses ethical dilemmas
faced by nurses and clients. How to resolve ethicaldilemmas in daily nursing practice and list of steps of
ethical decision making are elaborated. The fourth unit
comprises of confidentiality and informed consent andincludes definitions of both, importance of both anddiscusses nurse’s roles and responsibilities in nursing
ethics.
The fifth unit comprises of bills of rights andincludes definition of rights and bills of rights. It also
focuses on types of rights and role of nurse in relation
to bills of right. It also explains patents’ bills of rights ina tertiary health facility. The sixth unit covers code of
ethics and includes definition of code and code of
ethics. It also focuses on function and elements of
ethical code, application of code of ethics in clinicalsettings, comparison of code of ethics between
International council of nursing (ICN) and Pakistan
nursing council (PNC). This unit ends on explanationsof both ICN and PNC code of ethics. The seventh unit
covers professional autonomy and ethics and includes
definitions of profession and professional autonomy. It
discusses the characteristics of professional nurse andalso discusses professional autonomy and ethics. How
to relate nursing ethics to standards of nursing practiceis also covered. The eight unit covers ethical dilemmain professional practice. It defines dilemma andprofessional obligation, how to identify common areasof negligence and nurses liability in these areas.
Discussion of nurse’s advocacy in various scenariosand clinical cases related to life support equipment, risk
management and occupational hazards are included. It
includes documentation of nursing care, employment
issues and medical malpractice lawsuit.
The last ninth unit covers international healthorganizations and nursing organizations. It focuses on
identification of nursing organizations all over the world,
functions of international council of nursing and role ofworld health organization (WHO). It concludes on
elaborating the functions of Pakistan nursing
association, federation and council.
The results of this study show that undergraduate
nursing students have good knowledge about nursing
ethics. The questionnaire of this study comprises of 12questions and Likert scale is used to calculate theresponses of participants. In the response to firstquestion about main ethical principles and theories 26
students (65%) were of the view that they have highknowledge about ethical theories and principle, 12
students (30%) said that they have very highknowledge and 2 students (5%) have moderateknowledge. The second question asked the students
about key concepts of nursing ethics, in reply to this 25
students (62.5%) students said high and 11 students(27.5%) replied that they have very high knowledge ofthe key concepts of nursing ethics and 4 students

Eubios Journal of Asian and International Bioethics 26 (May 2016)(10%) replied that they have moderate knowledge. In
the third question students were asked that if they canidentify ethical issues and relate it to nursing practice,
20 students (50%) replied with high and 14 students(35%) relied that they have very high knowledge andthey can identify ethical issues and can relate thoseissues to their clinical nursing practice, 6 students(15%) were of the view that they have moderateknowledge. When asked about the conflict arising in
nursing due to different value and culture systems, 21
students (52.5%) said high and 14 students (35%) said
that they have very high knowledge and only 5 students(12.5%) replied that they have moderate knowledge.
The fifth question focuses on nursing ethics
curriculum and its contents and 27 students (68%)
replied with high and 10 students (25%) relied that they
have very high knowledge of nursing ethics curriculum
and contents of course, 3 students (7.5%) relied withmoderate knowledge. In reply to sixth question about
their application of case based reasoning in resolving
ethical problems, 24 (60%) students replied with highand 12 students (30%) replied that they have very highknowledge and they can apply case based reasoning
while resolving ethical problems, 4 students (10%)
replied with moderate knowledge.
The seventh question was asked about the
ethical issues arising due to organ donation and in reply
to this 24 students (60%) have high knowledge and 9
students (22.5%) have very high knowledge and only 6
students (15%) said that they have moderateknowledge about ethical issues arising due to organ
donation, 1 student (2.5%) replied that she has low
knowledge about the issue.
The eight question highlighted the most important
issue and asked about informed consent and its
meaning in health care and in reply to this 22 students(55%) replied with high and 17 students (43%) repliedthat they have very high knowledge about the concept
of informed consent and its meaning in health care,while only 1 student (2.5%) replied with moderateknowledge option. The ninth question asked about theadvance directives when the patients are terminally ill,
27 students (67.5%) replied with high and 5 students(12.5%) replied with very high knowledge, 4 students(4+4 (20%) each replied with moderate and low
knowledge about the concept of advance directives interminally ill patients. In reply to the tenth question
regarding brain death diagnosis in the patients, 21
students (53%) replied with high knowledge and 9
students (23%) replied with very high knowledge, 7
students (18%) replied with moderate, 2 students (5%)
with low and one student (2.5%) replied with very low
knowledge.
th
In the 11 question it was asked if they
understand the code of Pakistan nursing council, 21
students (52.5%) replied with high and 15 students(38%) replied that they have very high knowledge andthey can understand code of Pakistan nursing council,
4 students (10%) replied with moderate knowledge. In
the reply to the last question about the moral andethical issues arising due to withholding and with117

drawing life sustaining treatments, 21 students (53%)
replied with high and 13 students (33%) replied thatthey have very high knowledge about the ethical issues
arising from withholding and with drawing life sustaining
treatments, while 2 students (5%) relied with low
knowledge. The results of this article show theperception of undergraduate nursing students regarding
nursing ethics at Nursing Institute LUMHS Jamshoro.
Conclusion
The students’ evaluation of nursing ethics showsthat the undergraduate nursing students do have soundknowledge about ethical issues in nursing field and they
are able to identify and resolve those ethical issues anddilemmas. In addition to this it is shown that they also
have good knowledge about modern medical/nursing
care like organ donation issues, withholding and withdrawing life support equipment, brain death anddiagnosis issues, informed consent process andadvance directives in terminally ill patients. They
students were fully aware of their nursing ethics
curriculum and course contents and they found theircurriculum comprehensive. This study will further help
to identify the gaps in knowledge of clinical care amongnurses and also in further improvement of the nursing
curriculum and undergraduate teaching.
References
1. Leyla Dinc and Refia Selma Gorgulu. Teaching ethics innursing. Nursing Ethics. 2002; 9(3).
2. Farkhondeh Sharif and Sara Masoumi. A qualitative studyof nursing student experiences of clinical practice. BMC
Nursing. 2005; 4:6.
3. Girija K. Madhavanprabhakaran Et Al. Undergraduate
Nursing Students’ Perception of Effective Clinical Instructor:
Oman. International Journal of Nursing Science. 2013; 3(2):38-44
4. Helen Edwards Et Al. Impact of clinical placement location
on nursing students competence and preparedness forpractice. Nurse Education Today. 2004; 24(4):248-255.

Prospects and Problems ofStem Cell Research in
Bangladesh: Can Equity andJustice be Maintained in theContext of Public Health
Demand?
1- Abu Sadat Mohammad Nurunnabi
Erasmus Mundus Master of Bioethics student, Centre for
Biomedical Ethics and Law, Katholieke Universiteit Leuven,
Belgium. Email: shekhor19@yahoo.com

Abstract
Background: The aim of this paper is to justify whether
and to what extent access to expensive, technicallydemanding stem cell research or therapy could bepossible for the poor population in terms of equity and118

Eubios Journal of Asian and International Bioethics 26 (May 2016)

social justice in Bangladesh. Methods: A total numberof 51 articles were scrutinized based on specificthemes, following searches in PubMed, Hinari, Web ofscience, Web of Knowledge and Google Scholar
databases, between September 2011 and May 2012.
Moreover, different guidelines were taken into
consideration. Results: Stem cell research is in its
primary experimentation level and the results are still toachieve. Religious barriers and moral judgments,
economic constraint and social justice are key issues instem cell research in Bangladesh. Bangladesh lacks
minimal health care service, pure water supply andsanitation for its population with a struggling healthbudget and the agendum of stem cell research isabsent there. Based on equity and justice, it is stillquestionable whether to go for stem cellresearch/therapy, where its impact in public healthsetting is very low let alone allocate public funding oreven to allow private investment/collaborative researchon stem cell. Conclusion: For a resource poor healthcare setting in Bangladesh, involvement of publicfunding in stem cell research should be made in
research support when this research is only reasonably
related to the promotion and protection of public health.
Besides, a concrete guideline needs to be formulated tomonitor and prevent commercialization and exploitation,
addressing religious and cultural values.
Key words: Stem cell research, Stem cell therapy,
Public health, Equity and justice in health care.
Introduction
Stem cells are primitive cells having the capacity
to divide and give rise to more identical stem cells or to
specialize and form specific cells of somatic tissues (Loand Parham, 2009; Chapman, Frankel and Garfinkel,
1999). Two types of stem cell can be distinguished:embryonic stem cells which can only be derived frompre-implantation embryos and have a proven ability toform cells of all tissues of the adult organism(pluripotent), and adult somatic stem cells, which arefound in a variety of tissues in the fetus and after birthand are, under normal conditions, more specialized(multipotent) with an important function in tissue
replacement and repair (de Wert and Mummery, 2003;
Keller and Snodgrass, 1999). These cells are uniquecells that are undifferentiated and have the ability to
self-replicate indefinitely (Holland, Lebacqz and Zoloth,2001). They offer great promise for understanding basic
mechanisms of human development and differentiation,
as well as the hope for new treatments for diseases
such as diabetes, spinal cord injury, stroke, Parkinson’s
disease, and myocardial infarction (Lo and Parham,
2009; Committee on the Biological and Biomedical
Applications of Stem Cell Research, 2002). In spite ofgreat advantages, stem cell therapy has potential
complications and disadvantages that consist mainly oftumour formation, genetic abnormalities, infection,
tissue rejection, immunological complications, failure
rate and high cost (Larijani and Zahedi, 2008;
Chapman, Frankel and Garfinkel, 1999).

Stem cell research has been accompanied withnumerous ethical, economic, and organizational
problems related to the issue of equity, social justiceand policy making. As stem cell technology progresses
to the clinical setting, health care systems, especiallypublicly funded health care systems concerned withaccess, fairness, and cost control, will probably bechallenged to derive, expand, and distribute cells andtissues routinely and on a massive scale (Moazam,
2006; Kneopffler, 2004). One of the key ethical issues
in the stem cell policy is proportionality. It needs toweigh up the potential therapeutic benefits of theprocedure of stem cell research against its potential
harms and disadvantages (Larijani and Zahedi, 2008).
On account of the fact that stem cell research could be
an unrivalled approach to save many lives, it is difficult
to argue that research into human embryonic stem cell
is disproportional. On the other hand, the obligation to
pursue the best medical treatment is a prime duty;
therefore, it is not professionally acceptable forphysicians to let millions of people die or continue tosuffer from chronic and life-threatening diseases.
Beyond that, we need to weigh out the costs against
the benefits. Despite their promise, stem cell based
therapies are likely to remain, at least for many years,
both expensive and technologically demanding(Corrigan et al., 2006). Distributive justice (to allocate
justly the medical resources, costs and benefits, among
the community) is, therefore, an important concern. Just
distribution of potential benefits from stem cell researchneeds coherent well-structured planning. Equity,
fairness and equality are the main factors in this issue.
Justice, as the primary ethical consideration in healthcare resource allocation, should be considered at thenational level (Mitton and Donaldson, 2004).
Bangladesh is a poor, developing country in South
Asia (World Bank 2009). Poverty reduction,
improvement of health, especially of the poor, andminimizing socioeconomic inequities have been the
major focus of development strategies in the developing
nations during recent years. Poverty and ill health areinterrelated in a bi-directional way, meaning thatpoverty results in ill health and ill health leads topoverty (ICDDR,B, 2010). The health and poverty
situation in Bangladesh is typical of the other poor
nations. Nearly half of the Bangladesh population lives
below the poverty line. The life expectancy at birth isaround 60 years characterized by high infant andchildhood mortality. The maternal mortality ratio isaround 380 per 100,000 live births (BBS, 2009). Undernutrition, malnutrition, diarrhoeal disease, endemic
diseases like malaria, kala-azar, dengue, and highincidence of tuberculosis remain to be the major
problems. Despite improvement in health outcomes in
the recent past, socioeconomic, gender, andgeographical differences in health and in utilization ofhealth care services still persists implying that health ofthe disadvantaged segment of the population is yet
worse than the better offs and this trend is likely tocontinue (ICDDR,B, 2010). Moreover, sanitation
problems are acute in many communities, particularly inEubios Journal of Asian and International Bioethics 26 (May 2016)
urban slum areas (World Bank, 2009). Providing abasic health care facility for the people with equity andsocial justice is still a great problem in this country.
Bangladesh is still lagging behind in the field of
human stem cell research in the region. Neighbouring
countries like India and Pakistan have made muchprogress in stem cell research and tissue banking bothin public and private sectors (Moazam, 2006). Even nonational guideline has been set for ‘stem cell research’yet in the country (BMRC, 2011) to pave the way for
wide-ranging researches, where as the researchers
have an obligation to observe some moral values.
However, few researches are going on there throughprivate sector sponsorship and in collaboration withforeign countries. ‘Tissue Banking and Biomaterial
Research Unit’ of Bangladesh Atomic Energy
Commission (BAEC) regularly providing radiation
sterilized amnion membrane and bone allografts todifferent hospitals and clinics throughout the country. At
present, 109 hospitals and clinics and more than 300
surgeons and physicians are involved with this unit
through utilization of radiation sterilized tissue allografts(Zahid et al., 2010). Even some of the private tissue
banks are working on commercial basis by exporting
tissues abroad. Some organizational policies do notaddress commercialization, while others fail to consider
confidentiality and quality of research (Zahid et al.,2010). However, even in those instances where one of
the four factors is recognized by all policies(commercialization, confidentiality, informed consent,
and quality of research); there is often a lack of
uniformity in its meaning, scope, and ethicalsignificance. Until uniform ethical guidelines regulating
the storage, distribution, and use of human tissues forresearch are established, the international transfer ofhuman tissues and multinational research involving
industry will not only remain cumbersome, but, in many
instances, ethically problematic (Zahid et al., 2010).
Moreover, there is no preparation for the government togo for stem cell research or allocate public funding forthis in annual health budget. Besides, government
health departments i.e. Ministry of Health and Family
Welfare of the People’s Republic of Bangladesh or
Bangladesh Medical Research Council, the highest
ethical body of the country, are yet to implement a
policy or guideline for stem cell research (BMRC,
2011). Several proposals have already been given to
the authorized bodies to make a national guideline(Zahid et al., 2010).
While the national budget is still under pressure toprovide primary health care delivery to the people andachieving the Millennium Development Goal (MDG) by
2015, an endeavour like stem cell research, which isvery expensive and technically demanding matter,seems a day dream to the Government of Bangladesh.
Health related research in developing countries is anecessity.
Bangladesh
needstoinvestigate,
understand and develop effective preventive andcurative approaches to diseases that are endemic tothis region. But the benefits of such research must
accrue to the communities used for research (Moazam,

1192006). It is known to many that the ‘10/90 gap’described in the 2001–2002 Report of the Global Forumfor Health Research (Global Forum for HealthResearch, 2002) is really critical. The report highlights
the fact that of the 73 billion USD USA was investingstannually in health research at the turn of the 21
century, less than 10% was being devoted to healthproblems that account for 90% of the global disease
burden and those are related to problems of thedeveloping countries. Hence, public funding or private
investment on stem cell research and therapy in aresource poor country like Bangladesh is a matter ofgreat debate, as we are still fighting public healthproblems with communicable diseases e.g. diarrhoea,
malaria, kala-azar, TB, and non-communicablediseases e.g. diabetes, cancer etc. where enormous
funding is needed for providing health care support, lifesaving drugs or vaccination and health research inthose fields. The national annual budget is still facing
crisis to meet the basic needs of people e.g. fooding,housing, pure water supply and sanitation, minimum
health care support and treating and preventing
endemic diseases.
As stem cell research and therapy is very
expensive and highly technical in its application,accessibility to it is still questionable in context of publichealth need and public funding in a developing country
like Bangladesh. There is much more to reveal thefacts, consider the ethical suitability, and above all,formulate regulations maintaining the equity and justicein public health care for people. The aim of this paper is
to analyze the research on stem cells in relation withthe goals of public health in Bangladesh and find out
the answer to the question as some parts of the
population have no access now, or only to basic healthneeds, whether and to what extent to give them accessto an innovative, expensive and highly technical stem
cell therapy or is it really feasible to ensure theaccessibility of its hopeful results for the population in
general in terms of equity and social justice.
This work was aimed to evaluate the main aspects
involved in the decision-making process regarding stem
cell research in a developing country perspective e.g. in
Bangladesh. Mainly two aspects will be analyzed here:
Firstly, it would be tried to determine if it is reallyjustifiable for a poor, developing country like
Bangladesh to go for an expensive, technicallydemanding stem cell research at this present economic
condition, where providing a minimal health carefacilities for the people is still a burden for thegovernment or state, based on current public healthproblems, goals of public health and health budget
allocation.
Secondly, different guidelines for stem cell researchboth in developed and developing countries will betaken into consideration, and analyses will be done tofind out the common approaches and directives that
could be useful for all stakeholders for their better
understanding and decision making regarding
prospects and problems of stem cell research, publichealth strategy, health research strategy, public funding

120

Eubios Journal of Asian and International Bioethics 26 (May 2016)

and privatization of the process. The ethical aspects
implied in each of these sections will be analyzed.
The potential contribution expected from this work
is a better understanding of the position of different
stakeholders like physicians, researchers, patients,
public and private health care institutions, religious
leaders, government regulatory bodies concerning theprospects and problems of stem cell research in adeveloping country in relation to equity and justice inhealth care. This knowledge could be useful for dealing
with the complexity of the situation, to improve
communication among all these groups of persons, andto help all those concerned in the decision-making
process.
Methods
An extensive literature review was done between
September 2011 and May 2012 based on searchingfrom the following databases: PubMed, Hinari, Web ofscience, Web of Knowledge and Google Scholar. The
key words used for searching were ‘stem cell’, ‘stem
cell research’, ‘developing country’, ‘ethical issue’,‘equity and justice in health care’. Latest articles (forexample, published in last 10 years) were primarily
searched. Moreover, the guidelines proposed by theEuropean and North American Medical and Bioethical
Associations, and National guidelines of different
neighbouring countries like India and Pakistan, andother Muslim countries in the Middle-East, resourcepoor, developing countries of Africa as well as
institutional directives were collected.
A total number of 239 literatures were identified.
Then the literatures were scrutinized based on theircontents, and according to the some specific themes
like ‘prospects and problems of stem cell research’,‘stem cell retrieval’, ‘ethical concerns relating todeveloping countries regarding stem cell research’,‘current crucial problems in health care system in
Bangladesh’, ‘question of distributive justice and equity
in public health strategy regarding stem cell researchand therapy’. After these selection criteria only 51
literatures were identified those are relevant to myproposed work.
Results
Based on specific themes or selection criteria a
total number of 51 articles were identified. My proposed
work was based on these literatures. Among them I
have categorized as prospects and problems of stem
cell research (37), stem cell retrieval (21), ethicalconcerns relating to developing countries on stem cellresearch (15), current crucial problems in health caresystem in developing countries focusing on Bangladesh(9), question of distributive justice and equity in publichealth strategy regarding stem cell research andtherapy (6).
Reviewing the articles related to prospects andproblems of stem cell research, it was found that stem
cell research or therapy is a promising innovation in
medical science to provide better treatment and reducethe disease burden, especially if it is based onembryonic stem cells. However, it is in its primaryexperimentation level and the results are still toachieve.
Stem cell retrieval is of a great ethical debate.
Religious barriers and moral judgments have risen a lotof controversies, particularly dealing with embryonicstem cell and production of human embryos for that
purpose. However, those gaps can be minimized
through involvement of different stakeholders andcreate common approach.
It was evident in different articles that current publichealth concerns in Bangladesh are providing minimal
health care service to people of all ages, providing purewater supply and sanitation, vaccination, andprevention and reduction of maternal and child mortality
rate and achieve millennium development goals (MDG).
The agenda of stem cell research/therapy was absent
there.
Ethical concerns in stem cell research in adeveloping country like Bangladesh are many. Moralvalues, cultural differences, religious barriers and social
taboos play important roles. Besides, public healthproblems addressed in local settings are different andfar apart from modern stem cell research/therapy.
Based on equity and distributive justice, it is stillquestionable to go for stem cell research/therapy where
its impact in public health setting is very low let alone
allocate public funding or even to allow private
investment/collaborative research on stem cell.
Discussion
It has been stated that human embryonic stem
cells (ES cells) derived from early embryos
and embryonic germ cells (EG cells) have particularpromise for a wide range of therapeutic applications
because they are capable of giving rise to virtually any
cell type. Research on these primordial cells will also
provide a unique opportunity to study human cellbiology. Adult stem cells, obtained from mature tissue,
differentiate into a narrower range of cell types. As aresult, many cells of medical interest cannot currently
be obtained from adult-derived stem cells. It is also lessfeasible to develop large-scale cultures from adult stem
cells.
The ultimate step is likely to be taken towards the
improvement of transplantation therapy and toward
lengthening a person's life. I would like to postpone
discussion of life-extension, noting here the relevanceto transplantation medicine. Specifically, rejuvenation
through transplantation of tissue grown in a laboratoryfrom stem cells would be of enormous value
for cardiomyocytes to renew heart muscle to prevent
congestive heart failure; replacement of hematopoietic
stem cells for producing healthy blood in bone marrowtoresistinfection
by
the
human
immunodeficiency virus and to treat AIDS and possibly
sickle cell anaemia; cultivating endothelial cells to reline
blood vessels as treatment for atherosclerosis, angina,
andstrokedue
toarterial
insufficiency;
rejuvenating islet cells in the pancreas to produce
natural insulin to fight diabetes; renewal of neurons inEubios Journal of Asian and International Bioethics 26 (May 2016)
the brain to treat Parkinson's disease and victims ofstroke; fibroblast and keratinocyte cells to heal skin in
the treatment of burns; and chondrocytes or cartilage
cells to treat osteoarthritis or rheumatoid arthritis. Now,
the trick will be to discover just what turns which genes
on and off. Once scientists have learned how totrigger gene
expression,
they
can
apply
it
to pluripotent stem cells and direct the growth of
selected bodily tissue. Particular organs could be grownin culture. Heart tissue or entire organs such as thepancreas or liver could be grown in the laboratory.
These would be healthy rejuvenating organs ready fortransplantation. It is expected to bring a revolution in
the world of medicine and therapy, as public healthreally matters. However, the results are still to achieve.
The scientists and pharmaceutical companies are verymuch enthusiastic about the prospects of stem cell innear future.
The risks of innovative stem cell-based
interventions include “tumour formation, immunologicalreactions, unexpected behavior of the cells, andunknown long-term health effects” (Hyun et al., 2008).
Even with these safeguards, however, because of thehighly innovative nature of the intervention and limited
experience in humans, unanticipated serious adverse
events may occur. In older clinical trials oftransplantation of fetal dopaminergic neurons into
persons with Parkinson’s disease, transplanted cells
failed to improve clinical outcomes (Freed et al., 2001;
Olanow et al., 2003).
It was also evident that about 15% of subjects
receiving transplantation late developed disabling
dyskinesias, with some needing ablative surgery torelieve these adverse events (Freed et al., 2001;
Olanow et al., 2003).
Problems with informed consent are well
documented in phase I clinical trials. Similarly,
Participants in phase I stem cell-based clinical trials
might overestimate their benefits and underestimate therisks. The scientific rationale for human stem celltransplantation and preclinical results may seemcompelling. In addition, highly optimistic press coveragemight reinforce unrealistic hopes (Lo and Parham,2009).
As stem cell technology progresses to the clinicalsetting, health care systems, especially publicly funded
health care systems concerned with access, fairness,and cost control, will be challenged to derive, expand,and distribute cells and tissues routinely and on a
massive scale (Giacomoni, Baylis and Robert, 2007).
Nevertheless, because the study of human stem
cells is at an early stage of development, it is difficult topredict outcomes and findings at this point in time. As
more research takes place, the full developmental
potential of different kinds of stem cells will become
better understood. And to realize the potential healthbenefits of stem cell technology will require a large andsustained investment in research. The government is
the only realistic source for such an infusion of funds.
For those who are challenged daily by serious diseases
that could in the future be relieved by therapies gained

121

through stem cell research, public funding holds thegreatest promise for sooner rather than later research
results that can be transferred from the bench to thebedside. Without the stimulus of public funding, newtreatments could be substantially delayed and morecostly.
Besides, the commitment of government funds alsooffers a basis for public review, approval, andmonitoring through well established over-sightmechanisms that will promote the public’s interest in
ensuring that stem cell research is conducted in a waythat is both scientifically rigorous and ethically proper.
Additionally, public funding can contribute to soundsocial policy by increasing the probability that theresults of stem cell research will reflect broad social
priorities that are unlikely to inform research in theprivate sector.
Of course, there are some other favouring points
for encouraging stem cell research in context of publichealth benefit and economy. According to Caufield(2010), also described earlier, “....policy arguments insupport of stem cell research often use economic
benefit as a key rationale for permissive policies andincreased government funding. Economic growth, job
creation, improved productivity, and a reduction in theburden of disease are all worthy goals and, as such,can be used as powerful rhetorical tools in efforts tosway voters, politicians, and funding agencies.
However, declarations of economic and commercial
benefits can be found in policy reports, the scientific
literature, public funding policies, and the popular press
and tend to have created a great deal of expectation.
Can stem cell research really deliver on the economic
promise? And what are the implications of thiseconomic ethos for the researchers who must work
under its shadow?” The debates of funding andexpected outcome and ethical issues are increasing
day by day (Kirk, 2000). Moreover, in developed
countries like USA and UK, commercial enterprises thatare beginning to present research that is still in its
preliminary stages as proven therapy or treatment forvarious diseases (Biotechnology and Biosciences
Research Council, 2002). Desperate patients andmisinformed or unscrupulous physicians are being
approached directly by such for profit businessenterprises (Caufield, 2010), although the expected
results are still to achieve. And for a resource-poor
country like Bangladesh, it is still a matter of great
debate. The issue of neglected diseases research is
obviously of central importance to people living indeveloping countries (Médecins Sans Frontières 2001).
The concept of globalization is embedded in the
speedy development of technologies that haveenhanced communication and interconnectedness, andhave led to the rise of claims that the world has become
a global village. Though it is often said to bring newopportunities for sharing ideas and technologies, it isuncertain how far this has been realized in terms ofglobal health. What is presently apparent is that eventhough these technologies have been around for
decades, their potential to transform the health of the122

Eubios Journal of Asian and International Bioethics 26 (May 2016)global community has not been harnessed. The
resource constraints in developing countries do notpromote the development or acquisition of thesetechnologies.
Moreover, the viability of national regulatory
systems is continually being confronted by a global
market for health care that is driven by the forces ofinnovation
andhealthcare
consumerism. The
emergence of a global bio-economy has created theneed for transnational regulation of biotechnology andmedical products. While generating consensus in
health care policy formulation has always been achallenge, it is particularly so against the backdrop of
globalization where consensus needs to be located atboth national and international levels.
Just distribution of potential benefits from stem cellresearch needs coherent well-structured planning
equity, fairness and equality are the main factors in thisissue. Justice, as the primary ethical consideration in
health care resource allocation, would be considered atthenational,
provincial
andmunicipal
level(macroallocation), at the level of institutions(mesoallocation), or at the level of the individual patient(microallocation). At the level of meso- andmicroallocation, clinicians often find themselves in therole of manager, being required to set priorities, or
affected by the decisions of others about priorities(Singer, 2000).
There will inevitably be opportunity costs for cashlimited healthcare systems considering making suchtreatments available. If healthcare services decide notto fund stem cell therapies, these therapies would beavailable only to individuals wealthy enough to pay for
their own treatment. The issues of social justice andequity arise if the opportunity to live longer is available
only to those who can afford access to an expensive
treatment. It is suggested that a more rational approach
would be to ensure ‘commensurate work in ethics andsocial policy’ to devise ways of coping with newchallenges (Corrigan et al., 2006).
Undoubtedly, rising public and professional
expectations, an expanding pool of treatable patientsand costly new technology must be balanced againsttightly monitored health care budgets, competinggovernment priorities in public health issue (McKneallyet al., 1997). What is required, and indeed what
decision makers seem to be asked for, is a systematic,
explicit approach to priority setting which is fair and,
where possible, evidence based in current situation(Mitton and Donaldson, 2004).
Bangladesh is a country of about 140 million
population with more than three-fourths majority ofMuslims. Stem cell research is a sensitive issue here in
its religious background (BBS 2009). Some Islamicscholars hold favourable views toward embryonic stemcell research from the perspective of Sharia (Islamiclaw) (Dabu, 2005). In Islam the embryo, even in the firstday of its existence, has the right of life and we have
any right to kill it. However there is a distinction
between different stages of human development inuterus (Larijani and Zahedi, 2007). Most of thesescholars believe that ensoulment of the embryo occursth
on the 120 day of the pregnancy, and that is the point
when it gains its moral status or rights as a legal
person. Some Islamic scholars, however, saythensoulment occurs on the 40 day (Dabu 2005). It is
worth noticing that notwithstanding the acceptability ofhuman embryonic stem cell research, the industrial
creation of human embryos and their destruction in
great numbers would be morally challenging in many
jurisdictions (deWert and Mummery; 2003), especiallyfor Bangladesh for existing majority Muslim population.
Even they are ready to ban embryonic stem cellresearch or therapy in any way.
The therapeutic potential of stem cells for treating
and possibly curing many serious diseases constitutes
a major rationale for large-scale investments of public
and private resources in human stem cell research. To
justify doing so, however, requires some assurance thatpeople in need will have access to the therapies as
they become available. Principles of justice are basedon treating persons with fairness and equity anddistributing the benefits and burdens of health care as
fairly as possible in society. This would require
equitable access to the benefits of stem cell research,without regard to the ability to pay.
Several factors make it unlikely, however, that there
will be equitable access to the benefits of this researchin this country. Even in the United States, 44.3 million
people (16.3% of the United States population) lackhealth insurance and therefore do not have reliable
access even to basic health care. Others are underinsured. Moreover, if stem cell research results in highly
technological and expensive therapies, health insurers
may be reluctant to fund such treatments. And indeveloping countries like Bangladesh, generally groupsof people suffer lacking good treatment, free supply of
drug and hospital care, even in low-cost government
facilities. They cannot think of minimum costs forregular health check-up and treatment in need let alonestem cell therapy.
Another factor complicating the commitment to justaccess is the central role of the private sector in stem
cell development. The private sector makes
determinations about investments on the basis ofpotential profitability. This has several implications. The
private sector will not invest resources in potential
applications that they consider lacking in commercial
value, but that may have considerable therapeuticpromise. Commercial considerations will also affect thepricing of stem cell products. Here again, market
concerns could raise prices, making stem cell therapies
more expensive. Unless the federal government
assumes a central role in setting priorities and investingin stem cell research, some of the most needed
therapies may not be developed. These justiceconsiderations are a further reason for encouraging
federal support for stem cell research.
Problems of access and equity are even greater ona global level. Vastly unequal resources, differential
standards of public health, and uneven opportunities forhealth care within and between countries compriseEubios Journal of Asian and International Bioethics 26 (May 2016)barriers to achieving even a semblance of distributive
justice. The World Health Organization has remindedmember states that “justice demands equitable accessto genetic services.” WHO has also stated that “Genetic
services for the prevention, diagnosis and treatment ofdisease should be available to all, without regard toability to pay, and should be provided first to those
whose
needs
are
greatest.”http://www.counterbalance.org/stemcell/justiref030.html It will be difficult to achieve these norms ina global economy in which transnational corporations
play a dominant role and disparities of all types are
ever growing greater.
Conclusion
In the context of stem cell research, theunderstanding of the limits of public health situation,
health research strategy and existing policy ofBangladesh appear to lead to three practicalconclusions. One is the commitment to involvement ofpublic funding should be made in research support
when this research is only reasonably related to thepromotion and protection of public health. The second
is respect for opposing views should be maintained,
especially those based on deeply held Islamic religious
grounds especially concerning use of embryonic stem
cells, to the extent that this is consistent with publichealth need and safety. And the third is to makesupport available to private investment or collaborative
research into alternative sources and/or methods forthe derivation of stem cells and into further initiatives onadult stem cells by adopting a concrete guideline
addressing the equity and justice for all and preventionof commercialization and exploitation.
However, the accessibility to stem cell research isstill questionable in a developing country like
Bangladesh in context of need-based approach in
public health. Overcoming these hurdles and assuring
equitable access to the benefits of stem cell research inthis country will be a politically and financiallychallenging task. It is, therefore, appropriate to begin
considering how to do so now in advance of thedevelopment of applications. There is much more toreveal the facts, consider the ethical suitability, andabove all, formulate a guideline maintaining the equity
and justice in public health care for people. Therefore,
the policy making part of the government e.g. Ministryof Health and Social Welfare, National Ethics
Committee of Bangladesh Medical Research Council(BMRC) and local scientists as well as think tanks
should consider ways to achieve equitable access tothe benefits derived from stem cell research in amodern era.
Acknowledgements
I thankfully acknowledge my supervisor Prof. (Dr.) Evert
Van Leeuwen, Chair, Section of Ethics, Philosophy andHistory of Medicine, IQ Healthcare, Radboud Universiteit
Nijmegen, the Netherlands; and Prof. (Dr.) Pascal Borry,
Centre for Biomedical Ethics and Law, Katholieke Universiteit
Leuven, Belgium, for their cooperation, critical comments and123

suggestions from the very beginning of this work up to its
completion.

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Eubios Journal of Asian and International Bioethics 26 (May 2016)

Medical Experimentation,
Ethics and Regulation:
Some Strands of Enquiry- Ankita Chakravarty
Assistant Professor, West Bengal National University ofJuridical Sciences, No.12, LB Block, Dr. Ambedkar Bhavan,
Sector III, Salt Lake City, Kolkata, West Bengal 700098

Abstract
Ethical concerns surrounding medical research inresource-poor settings. including the 'pharming' out or
outsourcing or ‘offshoring’ of clinical trials, and how
these relate to the economic, historical and politicaldimensions of the global scientific field, are a recurrent
theme across the different social science disciplines.
Ethical Questions and Unethical Cases
With regard to questions on clinical trials taking
place outside the US, the existing literature documents
engaging ethical questions and debates over standards
as well as divergent views articulated in course of such
ethical debates. Adopting a political economy
approach, Petryna (2007) and Fisher (2009) among
others clearly interrogate the global and local dynamics
of industry-led pharmaceutical trials, both in the US and`off-shore' clinical sites. They focus on thecommercialized clinical trials and the concept ofexperimentality to engage in a critique of neo-liberalism
and the concept of using vulnerable populations in
potentiallyexploitative
commercial
clinical
experimentation.
Typically sociological and anthropological research
on clinical trials has been extremely negatively oriented
towards the pharmaceutical industry and the sponsors
of clinical trials. However, in an interesting departure,
Montgomery (2010) points out that this approach isheavily focused on the testimonies of victims versus
exploiters and consequently, the process of theconstitution of the participant as subject via theresearch process is obscured in the righteous critiqueof transnational global forces. She notes that writing
about the trials as the process “through which medicallydrugged bodies emerge" eventually conjures an “imageof torpid zombies, devoid of agency and lacking mental
faculties.” So she cautions that in attending to themacro-level processes of clinical trials in which ‘theWest' is engaging in a one-sided exploitation of themarginalized `Other' what is obscured is the micro-levelstrategies and tactics of power that all actors utilize ininteraction with each other and the context.
A landmark case in the issue of ethics in human
medical research in global settings leads us to theplacebo controversy. Questions were raised overplacebo use in the trial of short course AZT treatment tohalt perinatal transmission of HIV in Africa (Angell,1997; Lurie & Wolfe, 1997; Petryna, 2005 & 2007).
Farell draws attention to the fact that it is not justprivate pharmaceutical companies who have been

125

conducting trials on the populations of the developing
countries; rather the US government through its
organizations, the Centers for Disease Control (CDC)
and the National Institutes of Health (NIH) had also
been actively sponsoring and conducting such trials.
These trials included some carried out on pregnant
women who were HIV positive in certain African
nations, the Dominican Republic as well as Thailand,
between 1994 and 1997 (Farell, 2006). The major
controversy was whether the use of placebo wasjustified although there were other allegations of
unethical conduct including lack of informed consent
procedures and also use of coercion. Not all thesubjects completely understood what the trial entailed,
the risks they would incur and what might be theimplications of receiving placebo. Consequently,
although an accepted standard of care existed, a large
number of cases with mother to child transmission of
HIV/AIDS were reported. The debate that emerged on
the placebo question related to whether it was ethicallyvalid to give less than the best known standard of careto the subject participants in the placebo control group.
The supporters of the trial asserted that since thewomen would in general be unlikely to receive anytreatment at all, the placebo was seen as conforming to
the best ‘local’ standard of care. Petryna (2007) has
emphasized that in effect they pointed to thespecificities of the local cultural variables andunderdeveloped health infrastructures to argue that thebest standard of care, was impractical. Hence, ethicalvariability, by which different contexts would determine
the different ethical standards to be observed, wasjustified.
The notion of cultural relativism was also invoked by
the supporters of the trial who argued that the conceptof right to informed consent was a Western constructwhich could not be applied to Africa due to its uniquecommunitarian social system. (Mason Meier, 2003)
Pointing out that vaccine testing is related to the politics
and economics of the drug market which has no
relevance to African culture, Mason Meier has argued
that the notion of cultural relativism was being used asa façade for what he has termed ‘cultural
rationalization’, wherein the concept of cultural
relativism has been invoked inappropriately bywesterners to justify and validate their own economic
and political ends. He also argues that there is no
credibility in the assertion that most African social
norms are communitarian to the extent that individuals
would forsake their right to informed consent. Further
arguing for the irrelevance of cultural questions in thissituation, he notes that the trial designs wereconstructed in western settings by western researchers
who had not even consulted African physicians.
Angell has also raised concerns about the ethicalstandards being observed with respect to clinical trials
on vulnerable populations as well as the population in
the third world. Drawing on the watershed case of
medical ethics in human experimentation, she
compares the Tuskegee study with the placebo arm of
the short course AZT trial. The Tuskegee study of126

Eubios Journal of Asian and International Bioethics 26 (May 2016)

untreated syphilis is one of the most publicized cases ofunethical research where a group of poor African
American men with syphilis were deliberately deceived
and not provided with treatment in order to chart thenatural progression of the disease (Angell, 1997). No
informed consent was obtained and a number of thesubject participants were misled to believe that they
were receiving treatment. The argument advanced insupport of the trial was that these poor men would
probably not receive treatment and hence, it did notamount to unethical conduct. It is not too much of astretch to say that the Tuskegee trial in fact provided
the basis for the later justification of placebo use in poor
participants from the developing countries.
Continuing with the problematic ethical practices
followed in clinical trials on vulnerable populations
especially in the developing world, the case of Pfizer’s
Trovan trials in Kano, Nigeria has been highlighted by
Farrell (2006). In 1996, the company was developing
Trovan (compound: Trovafloxacin), a potentially blockbuster antibiotic drug which would provide profits of $1
billion per year. In the same year, Kano- a city in
Nigeria had large-scale outbreaks of measles, cholera
and bacterial meningitis. On being informed of theoutbreak, the Pfizer medical team set up a temporary
treatment centre at the Infectious Diseases Hospital.
Two weeks after conducting the trials on the children,
the Pfizer medical team left and did not do for any posttrial follow-ups. Legal cases were registered against
Pfizer by Nigerian minors and their parents as they
alleged that 11 children had died and a number ofchildren had become paralysed, blind or deaf due to thedrug. They also alleged that individual informed consent
had not been taken and that the Pfizer authorities had
not explained that the treatment being provided wasexperimental in nature and that participants could infact refuse to participate. Further, Doctors without
Borders (MSF), an international charitable organization
was offering the standardized treatment adjacent to the
Pfizer facility. Farrell has argued that as part of theinformed consent process, the Pfizer team should haveinformed the participants that they could avail treatment
at the charity (Farrell, 2006). Not informing them of thealternative treatment available may have left theparticipants mistakenly believing that the trial drug infact, constituted treatment. The fact that it was an
epidemic situation or a crisis may have also blunted
their understanding of the risks involved and thereby
compromised their rational decision-making.
Farrell notes that David Carr has argued that theHelsinki guidelines offer a scope for obtaining
community consent in lieu of individual consent. This
leave room for the researchers to argue that Pfizer hadtaken consent from the Nigerian government and the
Hospital’s ethics committee; hence, they had actually
upheld the informed consent requirement. However,Farrell argues that this line of reasoning is problematic.
While the international ethical guidelines should be
sufficiently flexible to recognize cultural differenceswherein community leaders may be allowed to consent
on behalf of the population, it does not mean that

individual consent should be forsaken. Rather,individuals should also be asked for individual consent
along with the community’s consent.
This seems to recall Meier’s concept of cultural
rationalization - when such reasoning is being used toprotect the position of the company and its researchers,
it needs to be asserted that the point of such informed
consent procedures for clinical trials is not just as amere formality. It exists to ensure that the trial is being
conducted ethically in spirit, and not just as a matter ofcourse.
Pharmaceutical Industry and Regulatory Oversight
By highlighting the increasingly globalized operationof the clinical trial process, Petryna (2007) has sought
to show that trials are being outsourced to the Contract
Research organizations (CROs) which are private
sector services based companies specializing in the
conduct of clinical trials and drug development. She
also points out that as trials are being shifted to low andmiddle income countries, the public health care systemand quality of care available in these countries become
significantly contingent on them. Specifically focusing
on Eastern European (mainly Poland) and Latin
American (mainly Brazil) countries, she locates theuncertainties of the clinical trial process with what she
refers to as ‘the paradigm of expected failure’essentially, the failure to anticipate and thereby change
the potentially unsafe outcomes that may result. It
implies that the risks emerge after the drug has alreadypassed through the clinical trials, and as a result is asource of potential risk for the consumers or patients.
She also points to the context specific strategies ofevidence-making like engineering subject participant
choice so that results can be planned to a certain
extent which helps to increase the potential for successof the drug’s trial.
The question of lack of human protection in therealm of drugs necessitates enquiry into theorganizations responsible for regulation. Much of theliterature relates to the US FDA (Food and Drugs
Organization) which is responsible for drug regulationand supervision in the US. Widely acknowledged as themost powerful drug regulatory authority in the worldmainly due to the status of the US as the world’s largest
pharmaceutical market, the FDA has had to face
allegations of inappropriate behaviour since at least the
1970s. Abraham (2002) has analysed the potentiality of
regulatory capture by showing that there has been an
undue influence of the pharmaceutical industry on thefunctioning of the three major regulatory agencies in theworld. The FDA, the British Medicines Control Agency(MCA) and the European Union’s European Medicines
Evaluation Agency (EMEA) are taken up to highlightthat the many policies which are adopted due to heavy
industry lobbying, may be inimical to public interest. He
also addresses that conflicts of interest may arise whenregulatory bodies seek expert reviews, some of who
may have funding or other relations withpharmaceutical companies (Abraham, 2002). He also
sheds light on the politics of the ‘revolving door’ whichEubios Journal of Asian and International Bioethics 26 (May 2016)has also been addressed by Braithwaite (Braithwaite,1986). Essentially, the revolving door phenomenarefers to the fact that individuals may begin their careerin the industry, then work as regulatory officials forsome years before re-joining the industry at a higher
level. Regulators are also frequently employed bypharmaceutical companies after their regulatory careers
are over. Therefore, the possibility for regulators tohave a sympathetic leaning or more crucially, evenconflict of interest is not very remote. For instance,
regulators with a background in industry may bemotivated towards a pro-industry outlook keeping in
mind that their future prospects are dependent on being
perceived as industry friendly.
Marcia Angell (the erstwhile editor of The New
England Journal of Medicine) and Richard Horton (theeditor of Lancet) have also pointed to the suspicious
nature of functioning of the FDA and the extensive
influence of the pharmaceutical industry on theregulator’s regulations and their decisions (Angell, 1997
and Horton, 2001). Carpenter (2013) has howeverargued that the problem of regulatory capture in thesense of a strong tendency of the regulators to act in
the interests of the industry cannot be confirmed on thebasis of historical evidence of legislation. Rather, hemakes a case that over the last few years, thepharmaceutical sector has been characterized by the
weak or diluted application of laws, almost amount to
no regulation. This is what he refers to as corrosive
capture, wherein the independence of the drug
regulatory bodies has been compromised.
In a more recent account, the British physician
Goldacre (2012) has also highlighted the problem ofregulatory capture - firstly, due to the revolving door of
employees between the industry and the regulator;
secondly, as a result of the fact that the regulatory
officials and the company employees have common
interests and knowledge, friendships might develop
between them. Goldacre is one of a number of doctors
who have alleged that pharmaceutical fraud is an ongoing problem, not one which has been dealt with. He
has also pointed to the problematic nature of clinical
trials where he alleges that there is reporting andpublication bias in data. This is leading to a partial
representation of the actual evidences, what he refers
to as a ‘slow and unnecessary pollution of almost theentire evidence base in medicine’. Like Petryna, he also
raises questions on the functioning of the CROs andthe treatment of subject participants. Finally, he has
also pointed out that since doctors are also being
misled by the claims of the pharmaceutical companies,
the whole body of patients suffer through questionable
drug administration (Goldacre, 2012).
The Indian Experience
Srinivasan has also written extensively on theclinical trials sector in India. She has compiled a list ofsome of the different unethical trials in India which havebeen documented in public record (Srinivasan, 2005).
On the subject of the Indian government promoting
itself as a global gateway to clinical research, she

127

raises questions on the vulnerable nature of the subject
participants of such trials. She has raised questions
regarding the regulatory mechanism in place andargued that there is a need to establish accountability inclinical trials. She also quotes a survey (McDonald,2008) to show that a large number of the subject
participants actually participated in trials on the adviceof their family doctors who also happened to be the trial
investigators. Further, a significant portion of theparticipants were also participating because they werelooking for free and better health care. Public hospitals
in India provide free or reduced cost treatment and poor
people frequently seek treatment there. However, due
to the limited number of beds in most such hospitals aswell as the high burden of patients, there are serious
difficulties in getting access to treatment. However,participating in trials gets the patients access to thetreatment (Srinivasan, 2009).
Among others writing on clinical trials in India, Nayak
has taken up the problem of objectification of thehuman body in clinical trials and by extension, in the
medical scientific paradigm itself. She puts forward that
doctors tend to look on the human body of the patientor the subject participant as an object and for pragmatic
purposes, sites through which scientific knowledge canbe gained. She has also highlighted the inherently
hierarchical nature of the relationship between the
doctor and the patient (Nayak, 2011). Ignoring the issueof the rights of the patient, doctors are seen to have an
upper hand in all dealings with the patient and theinteraction is largely a one- way traffic.
Kaushik Sunder Rajan has offered a nuanced
understanding of the role of the larger Indian state(Rajan, 2006). In his comprehensive work Biocapital,
he has shed light on the links between contemporary
biotechnical advances and the social-political contexts
and economic markets within which they emerge.
Drawing on his ethnographic study of a private hospitalin Mumbai which conducts a number of clinical trials, hedisplays how the very geographical location of thehospital may ease access to a large group ofunemployed workers who provide a ready pool ofparticipants. The hospital houses a biotechnology
company which was seeded by a public sector
organizationinpartnershipwithaprivatepharmaceutical company. While the state is frequently
regarded as the protector of its citizens, Rajan hasargued that paradoxically the state itself acts as amarket agent because it makes these participants
available to pharmaceutical corporate interests, which
are frequently of western origins. Although allegationsof a ‘new colonialism’ have been levelled at the waythat unethical clinical trials have been organized inIndia mainly by western pharmaceutical interests(Nundy & Gulati, 2005), Rajan has looked at
outsourcing in terms of both the expropriation of thesubject participants in the developing world and the
exploitation of the patients who are on medication in thefirst world. Looking at the larger phenomena of clinical
trials and drug development, Rajan has shed light on
the complex ways in which biomedical research &128

Eubios Journal of Asian and International Bioethics 26 (May 2016)

financing, marketing practices and the regulatory
mechanism are shaped by the global economic
influences. Hence, there is a huge amount of buzz indifferent public and private sectors not just in in building
clinical research infrastructure in India but also inpromoting India as a favourable clinical trial destination.
The potential of Indian populations as trial subjects
offers one of many advantages which significantly
upgrade the market potential from increasing clinical
trials into India. What Sunder Rajan also clearly points
out is that this is happening at the precipice of asignificant historical time where the Indian state is
actively engaging in branding and marketing itself
globally. Hence, the role of the neoliberal state incontributing to the growth story of the Indian identity
finds expression in investments in infrastructure as well
as resource building for clinical trials.
Significantly it will be interesting to see what are thechanges which are being brought about by the newpolitical regime which has come to power in India andwhat are the implications going to be? Since this is aperiod of flux in the official approach, it is fair to say thatvery many changes are anticipated on the basis of theideology and philosophy the new government
espouses.
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