Asia-Pacific Perspectives
on Bioethics Education

Asia-Pacific Perspectives on Bioethics Education. Bangkok: UNESCO Bangkok, 2008.
v + 195 pp.
1. Medical Ethics. 2. Education 3. Philosophy 4. Bioethics. 5. Asia and the Pacific.

ISBN 978-92-9223-221-4 (Electronic version)© UNESCO 2008
Published by the
UNESCO Asia and Pacific Regional Bureau for Education
920 Sukhumvit Rd., Prakanong
Bangkok 10110, Thailand
Chief Editor: Daniel Calderbank
Editor: Darryl R.J. Macer
Cover design: Alessandra Blasi
Design/Layout: Celia H. Thorheim
Printed in Thailand
The designations employed and the presentation of material throughout the publication do not imply theexpression of any opinion whatsoever on the part of UNESCO concerning the legal status of any country, territory,
city or area or of its authorities, or concerning its frontiers or boundaries.
SHS/08/EP/016-1

CONTENTS
iii
ACRONYMSv
PREFACEvi
The importance of knowledge development in bioethics education
1
Ethical education in the medical curriculum – interns’ perspectives
9
Development of case study materials for teaching research ethics
11
Bioethics education in tertiary settings: The University of Malaya experience19
Ethical views of first-year medical and nursing students in a joint bioethics course
22
Bioethics education in Pakistan: challenges and prospects
27
Knowledge of bioethics among postgraduate trainees of a medical university in Southern
Pakistan: Do we need to teach Bioethics?
31
Ethics curriculum for postgraduates in obstetrics and gynaecology: How I see it
35
Teaching ethics and humanities to medical students in Sri Lanka: A multi-cultural approach38
Ethics in paramedical studies - mapping a new agenda
42
To accomplish the life education mission through bioethics courses in a medical school in Taiwan 49
Biomedical ethics education in post-communist Eastern Germany
53
Teaching moral values for high school students in the Indian context
57
Environmental education and eco-ethics – current trends in education
61
Value Education: Treasure of a Nation
64
Bioethics education trials at Ateneo De Manila High School in the Philippines in 2004-2005
70
This year’s flowers are redder than last year - a brief introduction of the bioethics project inthe High School affiliated to Beijing Normal University in 2003-2005
73
The actualities and prospect of bioethics education in a Chinese middle school77
To treasure your life, refuse drugs
80
Organ transplants and organ donation
84
Responses to bioethics education in selected schools in Tamil Nadu, India
87
International approaches to evaluation of bioethics education
93
Content analysis of bioethics reports
109
Teaching Compassion
118
Can formal education promote beneficence?
124
Bioethics: Love of life through the knowledge of chanting for health and peace132
An earnest appeal: We need spirituality in medical education
135
Perspectives on sex education
143
Toward Successful Bioethics Education
147
Changes in bioethics education in Japan, with special comments on medical ethics
education in Japan during World War II
151
Current status of ethics education at agricultural universities in Japan
154
Bioethics as a challenge
165
L’enseignement De L’ethique De La Science Et De La Technologie Dans Les Universites Africaines 168
Joint plan of action for regional networking in bioethics education towards better
bioethics education
171
Discussion
177
Lindsey Conner (New Zealand) -The Importance of Knowledge Development in Bioethics Education 178
A. Nalini (India): Ethics Education in Medical Curriculum: an Interns Perspective
178

Asia-Pacific Perspectives on Bioethics Education

CONTENTSiii

iv

Asia-Pacific Perspectives on Bioethics Education

CONTENTS
Juraporn Pongwecharak (Thailand): Progress Report: Development of case study materials
179
Maude Phipps (Malaysia): Bioethics Education in Tertiary Settings: the UM Experience
179
Noritoshi Tanida (Japan): Ethical Views of first-year medical and nursing students in a joint bioethics
course180
Aamir Jafarey (Pakistan): Bioethics Education in Pakistan: Challenges and Prospects
180
Anoja Fernando (Sri Lanka): Bioethics teaching in Sri Lanka, the current status
181
Daphne Furtado and Karuna Rameshkumar (India): Ethics in Paramedical Studies—Mapping a New
Agenda181
Dena Hsin-Chen Hsin (Taiwan): To accomplish the Life Education Mission through Having Bioethics
Courses in Medical Universities
182
Heiko Ulrich Zude (Germany): Biomedical Ethics Education in Post-Communist Eastern Germany
183
Senthil Kumaran (India): Teaching moral values for high school students- Indian context
185
M. Selvanayagam (India): Environmental Education and Eco-Ethics- Current Trends in Education
185
Michael A. Jothi Rajan (India): Value Education: A Treasure of a Nation
186
Ester Estrella M. Abito, Milarosa Librea and MaryAnn Chen Ng (Philippines): Bioethics Education
Trials in the Philippines
186
Duang-Kamol Charptrasert (Thailand): Computer Self-Efficacy and student-centred Learning ina Thai Secondary School
187
Liping Wang (China): This Year’s Flowers are Redder than Last Year- a Brief Introduction of the
Bioethics Project in the High School Affiliated to Beijing Normal University in the Past Two Years
188
Jianzhi Li (China): To Treasure your Life, Refuse Drugs
188
Yuan Yu (China): Organ Transplant and Organ Donation
189
Jayapaul Azariah (India): Responses to Bioethics Education across Cultures- a survey to assess thebioethical need across THE social strata in Tamil Nadu, India
190
Subrata Chattopadhyay (Nepal): An Earnest Appeal: We Need Spirituality in Medical Education
190
D.S. Sheriff (India): Perspective on the Role of Sex Education in the Changing Cultural Scenario andPsyche of Indian Personae in the 21st century
191
Christophe Kwami Dikenou (Togo): The Teaching of the Ethics of Science and Technologies
191
About the Contributors
192

CHRB: Convention on Human Rights and Biomedicine
CIOMS: Council for International Organizations of Medical Sciences
COMEST: World Commission on the Ethics of Science and Technology
CSR: Corporate Social Responsibility
GM: Genetically Modified
ELSI: Ethical, Legal and Social Impact
GMOs: Genetically Modified Organisms
HES: Human Embryonic StemHUGO: Human Genome Organization Ethics Commitee
IBC: UNESCO International Bioethics Committee
IDHDG: Internal Declaration on Human Genetic Data
IVF: In Vito Fertilization
LMOs: Living Modified Organisms
NGOs: Non-Governmental Organizations
NHMRC: National Health and Mecial Research Council (Australia)
OECD: Organization for Economic Cooperation and Development
RUSHSAP: Regional Unit for Social and Human Sciences in Asia and the Pacific
UNESCO : United Nations Educational, Scientific and Cultural Organization
US-EPA: US Environmental Protection Agency
US-FDA: US-Food and Drug Administration

Asia-Pacific Perspectives on Bioethics Education

ACRONYMSv

PREFACE
There has been universal agreement for more than a decade that bioethics education at all levels should
be provided to citizens through the adoption of the Universal Declaration on the Human Genome andHuman Rights by the UNESCO General Conference in 1997 and by the United Nations General Assemblyin 1998. The work of educators in moral values through millennia was applied to the issues raised byscience and technology.
Ever since UNESCO made ethics of science and technology one of its five priority areas, the organization
has been charged with promoting the education of ethical issues of science and technology. This volume
offers perspectives from persons in a range of countries across the Asia-Pacific region on bioethics
education, including the efforts of many to achieve these goals.

vi

Asia-Pacific Perspectives on Bioethics Education

UNESCO’s programme in this area aims to strengthen the ethical link between scientific advancement
and the cultural, legal, philosophical and religious context in which it occurs. UNESCO’s strategy inbioethics has been to act as a standard-setter on emerging ethical issues, to disseminate informationand knowledge and to help member states build their human and institutional capacities. The standards
include the Universal Declaration on the Human Genome and Human Rights, the International
Declaration on Human Genetic Data, adopted in 2003; and the Universal Declaration on Bioethics andHuman Rights, adopted by UNESCO’s 33rd General Conference, in 2005.
This collection of papers is the fifth in a series of books from RUSHSAP, UNESCO Bangkok offering Asia
and Pacific perspectives on ethics - each focusing on specific themes. The contents come from submitted
papers to the UNESCO Bangkok Bioethics conferences held in 2005 and they are assembled thematically.
They also include discourse from the conference, as intercultural communication is part of the essence ofdeliberation on bioethics. The first UNESCO Bangkok Bioethics Roundtable was held 11-15 September,2005 - the first event of its kind in Bangkok. It took place during the 60th anniversary celebrations of
UNESCO. It was the first Roundtable of the UNESCO Asia-Pacific School of Ethics, and a number of papers
here are from members active in ethics educational activities of this regional network.
The UNESCO Bangkok office is the largest UNESCO branch office in the Asia-Pacific region, which for
UNESCO includes 46 member countries from Turkey in the West, to Japan in the East, and New Zealandand 17 Pacific Island nations to the South. It is designated as the regional office for coordinating
implementation of UNESCO programmes on ethics of science in Asia and the Pacific with the Divisionof Ethics of Science and Technology.
In the preparation of this book, I would like to thank the active discussion and participation of all thepeople who attended the meetings. There are papers that were submitted from two UNESCO bioethics
roundtables in Bangkok, held in 2005 and 2007, and from a joint UNESCO-UNU Bioethics Roundtable
in Yokohama, Japan. The volume concludes with the Action Plan adopted at the UNESCO Asia-PacificConference on Bioethics Education, held together with Ewha Women’s University and the National
Commission of the Republic of Korea to UNESCO.
A special thank you is due to Daniel Calderbank for help in editing the papers, and to Frankie Keller
for transcribing the discussion from the 2005 meeting. Thanks to Alessandro Blasi for the cover design
and Celia Thorheim for the layout. We look forward to increased discourse on these papers and theyshould not be seen as the final word on these topics, but rather as ways to catalyze a greater regional
development of effective ways to teach and evaluate bioethics education.

Darryl Macer, Ph.D.
Regional Adviser in Social and Human Sciences for Asia and the Pacific,
RUSHSAP, UNESCO Bangkok.

The importance of knowledge development inbioethics education*
Lindsey Conner, Ph.D.
University of Canterbury,
New Zealand

Why knowledge development is important in bioethics education

Learning is also acknowledged as being the result of complex interacting influences (Davis, Sumara
and Luce-Kapler, 2000). Therefore teaching in bioethics contexts must recognize these interconnections
because of the inherent application to and impact on peoples’ lives. Furthermore, teaching in bioethics
contexts needs to use pedagogies that engage students in participatory and emergent activities(ones that arise as a result of the need to know or opinions) to enable the development of multiple
dimensions of knowledge. These dimensions include the scientific content as well as the personal,social and emotional aspects associated with any particular bioethical issue. Oulton, Dillon, and Grace(2004) highlight the importance of focusing on the nature of controversy, recognizing that opinions
are based on particular worldviews and critical reflection of personal views, as well as promoting openmindedness or willingness to accommodate new views, and develop a thirst for more information.
In New Zealand, teaching and learning in bioethics contexts is most directly addressed in senior biology
classes and has been part of a national curriculum since 1994 (Ministry of Education, 1994). There is no
mandated text for teaching senior biology in New Zealand. Rather, teachers tend to develop their own
materials (worksheets/ activity cards etc.) to supplement a range of available resources, including texts.
Many of these resources utilise constructivist approaches to teaching and learning (e.g. Jarvis, Hickford
and Conner, 1998). This means that the teacher is often a facilitator of learning (Conner, 2004a) who
assumes that people have different worldviews, points of view, values and understandings about theissues.
Furthermore, bioethics can provide learning contexts for addressing the recently developed priorities
for raising school student achievement in New Zealand (Ministry of Education, 2005, p.2). These priorities
include:• deeper knowledge in different subject areas;• stronger skills and competencies to apply, relate and create knowledge for specific• purposes and contexts; and• a stronger sense of identity and self, including belonging, relating and contributing to a number ofcommunities as well as to the well being of self, others, and the rest of society.

What knowledge needs to be developed?
Because investigating bioethical issues is complex, we need to consider what knowledge needs to be
developed in order for students to make sense of issues, to be able to critically evaluate them and topossibly take action based on this knowledge. The possibilities include:* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

We no longer consider science to be just a body of content knowledge or that learning simply involves
compiling a “toolbox” of skills. Science is more complicated than this and involves multiple connections
with the society in which it is practiced (Kumar and Chubin, 2000; Solomon and Aikenhead, 1994;
Yager, 1996). Personal, social and emotional dimensions, values and conventions particularly influencebioethics education.

1• Knowledge of the science/technology content;• Knowledge of reflective processes (individual views);• Exploration of morals/values (values clarification);• Knowledge about bias and how to detect it (values analysis);• Knowledge about political agendas
Recently, Sadler and Zeidler (2005) showed that tertiary students frequently relied on combinationsof rationalistic, emotive and intuitive knowledge as they worked to resolve scenarios about genetic
engineering.

2

Asia-Pacific Perspectives on Bioethics Education

The unit of work
The unit of work on bioethical issues associated with cancer described here, targets the areas of
improving literacy, deepening knowledge, enabling the development of skills for creating knowledge(through inquiry processes) and requiring students to work collaboratively and to contribute to thelearning community regarding their ideas about bioethics. Specifically, it was designed to address theachievement objective; “investigate contemporary biological issues and make informed judgements
on any social, ethical, or environmental implications” (Ministry of Education, 1994, p.28). The highstakes assessment for this section of the curriculum was in the form of an essay in an external national
examination. Therefore it was very important for students to develop skills in research and essay writing
as well as develop their biological knowledge about cancer and an understanding of the bioethicalimplications of causes and treatments and social implications of these.
The usual class teacher continued to teach the class during the intervention. A constructivist approach
explored students’ existing content and procedural knowledge and built on this through various
individual and group activities so that students could reflect on what they needed to know and what
they needed to do. Cueing students to identify their knowledge and next steps for inquiry, was used todevelop knowledge though building on existing knowledge, and extending or applying of content toclarify and analyse issues as well as develop knowledge of learning processes.
The activities that explored students’ existing knowledge were a questionnaire, a group brainstorm
activity, group discussions and journal writing. Small group work, scenarios, case studies and videos
were used as stimulus activities for getting students to clarify and analyse their values. These activities
broadened students’ views about the social and ethical issues and allowed them to develop strategies
for learning (Conner and Gunstone, 2004).
The investigative skills and attitudes required of students are clearly outlined in the curriculum document(Ministry of Education, 1994). Students were expected to ask a series of related questions of themselves,
their group and resource people, and then to refine these questions. As well, students were expected
to identify and process relevant information from a variety of sources and to evaluate the quality of
information gathered and its degree of relevance. The students planned their individual research, chosethe two types of cancer they wanted to investigate and derived key words and key questions that would
drive their work.

Research processes
The research methodology employed for the study was based on an interpretative case study approach(Merriam, 1988). Sixteen students from the same class volunteered to be part of the study. Theirknowledge of content and the personal, social and factors that influence peoples’ decision-making inbioethics were recorded by administering a questionnaire prior to the start and at the end of the unitof work. The differences in the number of causes of cancer, biological effects, treatments and social andethical implications mentioned were tabulated for each student who answered both questionnaires(Table 1). Some students were absent for one of the questionnaires which invalidated a comparisonof before and after the unit. These categories were also triangulated over several class activities. A
comparison of the above categories was also made between the pre-unit questionnaire, a brainstormactivity (although this was carried out in small groups at the beginning of the unit), and what students
wrote about in their essays (Table 2). Students’ knowledge was also established from a pre-unit interview(iv1) and a post unit interview (iv2). The teacher was also asked to comment on various aspects of theunit of work. All of these data sources have been used to indicate students’ knowledge development.
Table one. Differences in the number of ideas given in pre and post questionnaires (+ indicates moreideas in the post questionnaire, - indicates less ideas in the post questionnaire).
Biologicalconcepts

Biologicalimplications

Socialimplications

Basis for making
decisions

Ethicalimplications

Ann
Awar
Charlie
Kay
Lois
Liz
Mary
Mitchel
Naomi
Sally
Terri

-1
0
+2
0
-1
+2
+2
0
-1
0
0

0
0
0
+1
0
0
+1
+1
+1
0
*

+2
0
+2
+2
+2
+2
-1
+1
+1
+1
0

+4
-1
+3
+1
+1
+3
+1
+1
+2
+3
0

0
+1
+1
0
+2
0
-1
+1
+1
0
-1

* No answer provided in second questionnaire

Development of content knowledge
Table 1 shows the differences in the number of ideas students recorded in their pre and post unit
questionnaires. Only students who completed both questionnaires have been included.
When comparing the overall changes in the number of ideas for each student between the pre and post
questionnaires (+’s or –‘s across rows in Table 1), all students except Terri had a positive change. I suspectthat Terri did not treat the questionnaire very seriously, since she did not bother to answer the question
on biological implications in her second questionnaire, yet she had clearly indicated some biologicalimplications in the pre-unit questionnaire. Her essays however, provided evidence of her awareness ofmultiple social and ethical implications.
For the number of biological concepts linked with cancer (Table 1), three students had an increase andthree students had a decrease when comparing the data between questionnaires. Only 4 students
increased their number of biological implications in the post unit questionnaires. However 10 of the
11 students who completed the essays had an increased number of biological implications in theiressays compared with their pre-unit questionnaire (Table 2). Overall, there was little change in theidentification of biological concepts but most students increased the number of biological implications
associated with cancer.
Students’ existing knowledge was gauged from answers given in the pre-unit questionnaires and thestudents’ responses in the brainstorm activity. Table 2 records the number of answers in four different
categories (causes of cancer, biological effects, treatments and social and ethical implications) for the
pre-unit questionnaire and brainstorm. These totals were compared with the number of times students
mentioned these aspects in their essays.
The analysis of the brainstorm data is somewhat inferential for each student. The totals may represent
the ideas of other students as the brainstorms were carried out in small groups. For example Awar had
quite high values for his brainstorm categories (causes of cancer, treatments and social and ethicalimplications) but he did not identify these in either his first or second questionnaires (see Table 1). The
other students in his group for the brainstorm activity were not part of the study group. Table two showsthat most students increased the number of biological effects (BE) noted in their essays, compared with
the number stated in their first questionnaires. This is in contrast to the lack of changes noted in thenumber of categories between the pre-unit and post-unit questionnaires for biological concepts andimplications. Of the students who completed questionnaire 1, Naomi was the only student who did nothave an increase.

Asia-Pacific Perspectives on Bioethics Education		Student

3

Table two. Triangulation of knowledge for students who wrote an essay
Categories:

C- Causes of cancer
BE - Biological effects
Tr - Treatments

SI - Social and ethical implications*- a second essay
StudentAnn

Pre-unit
Questionnaire
2 BE

Brainstorm

8C
0 BE
11 Tr
4 SI

1
1C
3 BE
0 Tr
8 SI
3C
7 BE
3 Tr
1 SI

6C
8 BE
3 Tr
0 SI

4C
8 BE
4 Tr
2 SI

4C
9 BE
2 Tr
1 SI

2C
7 BE
3 Tr
6 SI

6C
7 BE
4 Tr
5 SI

4C
4 BE
4 Tr
6 SI

4C
9 BE
2 Tr
1 SI

6C
6 BE
3 Tr
2 SI

6C
7 BE
4 Tr
5 SI

0C
3 BE
3 Tr
1 SI

8C
5 BE
3 Tr
0 SI

4C
1 BE
4 Tr
6 SI

8C
5 BE
3 Tr
0 SI

5C
7 BE
4 Tr
3 SI

absent

2 SI
Awar

1 BE
2 SI

4

Asia-Pacific Perspectives on Bioethics Education

Charlie

1 BE
3 SI

Liz

0 BE
2 SI

Lois

3 BE
8 SI

Marianne

4 BE
8 SI

Mitchel

0 BE
7 SI

Naomi

5 BE
5 SI

Terri

4 BE
4 SI

Essay

2*
4C
0 BE
3 Tr
4 SI

2C
6 BE
4 Tr
2 SI

6C
6 BE
4 Tr
2 SI

1C
2 BE
4 Tr
7 SI

Interestingly, there were fewer social implications identified in the brainstorms than in the firstquestionnaires for most students. There is a possibility that the questions in the questionnaire prompted
students to think of the social implications. Also, students may have been more focused on the biologicaleffects and types of treatments, rather than the social implications when brainstorming their ideas.
Comparing the total number of categories for issues does not indicate the depth of discussion many
students afforded to some of the issues. Comments and essay extracts gave a much better indication of
how sophisticated some of their ideas became.

Development of reflective processes (individual views about theissues and about learning)
Examples of how the students reflected on their changes in thinking about the social and ethical issues
are given below. Ann (iv):“Yeah, I know I am more broad about it, I feel I’m more aware of all the contributing factors now,whereas before if I thought it was an old person and they are suffering you should just let themdie, but now I think well, they’ve got family and I can see all the contributing factors now.”“Yes, because at the start when you don’t really know anything, you just think that the government
should save everyone with a disease and give it all free. Then you realize that you can’t and thatpeople bring it on themselves all the time, and they know all the risks, that it is not fair to givethem all free treatment as it is to someone who didn’t know or couldn’t do anything about it, likehereditary type things.”
Sally was referring to smokers as the people that bring it on themselves. Many other students were alsoquite scathing of smokers who expect to be treated when they know the dangers.
Lois also considered that this unit had “made her think more”. Lois (iv):“I think it’s made me think more of like legal things. I thought it was medical, beliefs, family, butnever really thought about the bigger picture – in terms of society. It’s helped clarify what ethicalthings are.”
The statements above illustrate how these students were aware of their own thinking. They also revealthat the students had some preconceptions about what the social and ethical issues were and that theunit of work helped them to clarify and expand on these ideas. The teacher also commented on how heconsidered the unit had enabled the students to develop knowledge about the issues and to reflect on
their own ideas. Teacher:“They are more aware that there is more than just their one point of view. I think that they havegot a better understanding now of it from the patient’s point of view, from the family’s point ofview…. whereas before, they probably they wouldn’t have considered that those other points ofview really existed…. wouldn’t have thought about it much.”Many activities which explored of morals/values (values clarification), bias (values analysis) and multiple
perspectives also contributed to their change in knowledge about the complexity, contextual andcontingent nature of the issues.
The teacher also commented that the students were more self-starting this year and took more
responsibility for the inquiry process than students had done in previous years. This was partly due tohis insistence that they chose what content was important, and reflected on their learning in terms ofwhat they needed to do next.
Examples of how students reflected on their progress either in their journals (j) or in their interviews
or essays (e) are given below. The students varied in their use of reflective processes (Conner, 2002;
Conner and Gunstone, 2004). Some students identified the need to develop content knowledge andAsia-Pacific Perspectives on Bioethics Education

Ann’s comments show her reflection on her knowledge and awareness of how she thought. Sally’scomments below also show some reconsideration of the issues based on her increased knowledge as aresult of this unit, but it is her statement “then you realize” which suggests that she has reflected on her
thinking processes. Sally (iv):5essay-writing, whereas other students asked themselves questions that extended their knowledge. For
example, Charlie wanted to find out more about telomeres and about what happens to plants that havecancer. He found out that telomeres are like timekeepers in a cell and that their formation limits a cell’slife span and linked this to the concept of immortality. Liz also asked herself questions that she later
answered in her essay.
Liz (j): “Can you get cancer anywhere, or just anywhere you have fat or muscle or blood?”Liz (e): “Because cells are everywhere in the body, cancers can form anywhere.”
Another example was the sequence of questions about treatments in her journal.
Liz (j): “What methods do people seem to prefer to use when they’ve found out they have cancer?
Treatment, chemical, radiation, positive thinking, god, nature or surgery?”6

Asia-Pacific Perspectives on Bioethics Education

In her essay she mentioned the treatments of gene therapy, radiation therapy, chemotherapy, surgery
and genetic screening for hereditary types of cancer. She also extended her thinking around treatments
to include ideas about personal and social ethics.
Liz (e): “As the individual must decide on his or her own code of ethics in dealing with this disease,so must the collective body of society. In this the rights of every person must be considered.
However it is rarely cut and dried and the ethics involved in cancer cases are still being debated.
Human dignity, equality, protection, privacy and freedom are among each person’s rights. But
what about euthanasia?”
Using reflective and critical thinking processes to make decisions about what to include in her essay
helped her greatly.

Development of the personal, social and ethical issues
Many students related the content to personal behaviour as indicated by questions they asked about
sunbathing, smoking, diet and skin pigmentation during class sessions. Some students took into
account the personal or emotional aspects involved in decision- making when someone is diagnosed
with cancer. The following extracts provide examples of this.
Marianne (e): “The social implications of this disease are widespread as the families and friends ofpatients must also deal with the suffering and trauma of loved ones.”
Naomi (e): “For women with breast cancer the decision to have a mastectomy can be very
difficult.”
This last statement was linked to a question at the end of an activity which was: “If your sister had been
genetically screened and was found to have the BRAC1 mutation, would you recommend that she haveher breasts removed as a preventative measure?” Sally commented on decision-making in her journal.
Sally (j): “I can’t decide if I could have the opportunity to know or not about whether I had themutation BRAC1, whether I’d want to know or not. It’s like the question, if you had the choice,would you choose to know or not when you’d die?”This statement is an example of how students personalized the issues and reflected on how it would
affect them. A different activity that required students to assume they had lung cancer and got themto decide which treatment they would choose also made them personalize the issues (extent of thedisease, treatments and their side effects, costs etc.).
Table 1 indicates the changes in the number of social implications. These increased from the pre to thepost questionnaire for 8 of the 11 students, and decreased for Mary (Table 1). For ethical implications,
there was an increase for five students and a decrease for two students. This suggests that in general,the number of ideas about the social and ethical implications of the class increased by the end of theunit.

The number of social and ethical implications identified in students’ essays was disappointing. It
seems that the students did not use/transfer the concepts or ideas generated in the brainstorms, or
those identified in the questionnaires or class discussions to their essays. Only four students showed
an increase in the number of social and ethical issues mentioned in their essays compared with thenumber mentioned in their pre-unit questionnaires (Table 2). Students tended to expand on particularissues in their essays rather than extend the number of issues.

Students could have been given clearer guidance that it was important to include personal and social
implications in their essays. Often what is assessed drives what students produce (Conner, 2004b).
Students need to know what is considered important in terms of the scientific/technological knowledge,
personal/social opinion, demonstrating that decisions are often made in the pursuit of particularinterests and that benefits accruing to some may be at the expense of others. As educators we needto examine how we indicate the importance of this complexity of knowledge required to be criticallyevaluative of bioethical issues.

Conclusion
In this unit of work, the teacher indicated and directed students to use inquiry about new science/technology content, required students to question what they needed to know and do. This enabledstudent to develop their knowledge and appreciate the complexity, contextual and contingent nature of
the issues. If we are serious about our students being able to make informed decisions about bioethicalissues, then teaching and learning in bioethical contexts really needs to include ways to interconnect
knowledge of content with personal and social dimensions and needs to emphasize factors that
influence how decisions are made.

References
Conner, L. 2002. Learning about social and ethical issues in a biology classroom. Ph.D. thesis, Melbourne,
Monash University.
Conner, L. 2004a. Teaching values through the process of facilitation. Pacific Asian Education, Vol. 16,
No. 2, pp.65-80.
Conner, L. 2004b. Assessing learning about social and ethical issues in a biology class. School Science
Review, Vol. 86, No. 315, pp. 45-51.
Conner, L., and Gunstone, R. 2004. Conscious knowledge of learning: accessing learning strategies in a
final year high school biology class. International Journal of Science Education, Vol. 26, No. 12, pp. 14271443.
Davis, B., Sumara, D. and Luce-kapler, R. 2000. Engaging Minds: learning and teaching in a complex
world. Mahwah, N. J.: Lawrence Erlbaum Associates.
Jarvis, S., Hickford, J. and Conner, L. 1998. Biodecisions. Lincoln: Crop and Food.
Kumar, D. and Chubin, D. 2000. Science, technology and society: A sourcebook on research and practice.

Asia-Pacific Perspectives on Bioethics Education

Table 1 also shows that nine of the 11 students increased their ideas about the basis on which people
make social and ethical decisions. This is yet another example that the unit of work allowed students tobuild on their existing knowledge. The data indicates that although students were exposed to a rangeof social and ethical implications throughout the unit and were able to articulate these (questionnaires
and interview responses), they did not necessarily include them in their essays. Some students may
have thought that the biological facts were more important in the essay than their opinions about theissues, as indicated by the data for “BE” compared with “SI” for Awar, Charlie, Marianne, and Mitchel inTable 2. That is, their perceptions of what should be included in the essay in terms of biological facts
may have overridden their inclusion of bioethical issues. Perhaps if students had been given copies of
the group brainstorm sheets, they may have incorporated this information when planning their essays.

7

Dordrecht: Kluwer.
Merriam, S. 1988. Case study research in education. California: Jossey-Bass.
Ministry of Education. 1994. Biology in the New Zealand curriculum. Wellington: Learning Media.
Ministry of Education 2005. Educate, Ministry of Education Statement of Intent 2005-2010. Wellington:
Ministry of Education.
Oulton, C., Dillon, J. and Grace, M. 2004. Reconceptualizing the teaching of controversial issues.
International Journal of Science Education, Vol. 26, No. 4, pp. 411-423.
Sadler, T. D., and Zeidler, D. L. 2005. Patterns of informal reasoning in the context of socioscientificdecision making. Journal of Research in Science Teaching, Vol. 42, No. 1, pp. 112-138.
Solomon, J. and Aikenhead, G. 1994. STS education: International perspectives on reform. New York:
Teachers College Press.

8

Asia-Pacific Perspectives on Bioethics Education

Yager, R.E. 1996. Science/technology/society as reform in science education. Albany, NY: State Universityof New York Press.

Ethical education in the medical curriculum – interns’
perspectives*
A. Nalini, M.D. and G. Srivinas,
M.D.
Tamil Nadu Dr. M.G.R. Medical
University, India

The essence of the Hippocratic Oath is non-malfeasance and beneficence. Even before the period of
Hippocrates, a text of Ayurveda, Caraka Samhitha refers to “Dharma” or duties of physicians. “You shallnot desert or injure your patient even for the sake of your life”. In the present times, there are otherconsiderations in addition to non-malificence and beneficence. The physician has to take account ofpatient autonomy and distributive justice. Both ethical and economic implications of the choices ofdiagnosis and treatment are to be analysed. There are ethical, legal, social and human rights issues
related to bio-medical research with human participation, end of life care, abortion, assisted reproductive
technology, organ transplantation, genetic technology, embryo research and cloning, HIV/AIDS and soon. Training of doctors and other health care professionals should incorporate teaching of ethics toenable them to deal with the ethical dilemmas in professional practice.
Unfortunately, formal training in ethics is not a component of the medical curriculum in most of the
medical schools both in developed and developing countries. As remarked by a medical student fromthe US, ethics teaching to-day resembles basic sciences instruction before the Flexner Report (Michael
Sanders, 1995). There are a few medical colleges in our country where ethics education is imparted
systematically. The Medical Council of India has made recommendations that ethics should be includedin the curriculum.
A survey was conducted by the Department of Curriculum Development, The Tamil Nadu Dr. M.G.R.
Medical University, Chennai in four medical colleges in Tamil Nadu, a southern state in India. Data wascollected from interns undergoing training after completing four-and-a-half-years of study in medical
school. A structured questionnaire was used and 184 interns responded. Our aim was to analyze theirexperiences and views, a process which will facilitate planning of a formal ethics curriculum.
The study revealed that more than 60 per cent of the internees felt that they had opportunities tolearn about ethics during the MBBS course and they were able to discuss ethical issues with faculty
members. Forensic medicine and community medicine were the disciplines in which ethics was dealt
with. Three quarters of the participants were of the opinion that medical ethics should find a placein the curriculum as a separate subject of study, because the study of ethics will have an impact on
improving professionalism and that ethics should be taught throughout the course. The topics whichwere cited as important where patient autonomy, ethical theories, codes of medical ethics, rights andduties of doctors, cost constraints of patients, collection of fees by doctors, doctor-doctor relationships,
etc. Preferred teaching methods were seminars, clinical teaching and lectures. Suggested methods forassessment were case presentation, quiz and MCQs.
The formal curriculum helps the students to face ethical issues in their future practice. More importantly
is the informal curriculum, that is, learning about ethical behaviour from good role models. The
significance of this hidden curriculum is reflected in the remark by one of the internees: “Ethics is learnt
by observation and practice and not by mere teaching.” On the other hand, behaviour in the clinicalsettings which is perceived as unethical makes the students uncomfortable. In our study, the interns* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

In recent decades, advances in medical sciences and technology have altered the way in which medicine
is practiced and the traditional doctor-patient relationship. The enormous increase in knowledge has
empowered the health care professionals to achieve standards of diagnosis and treatment whichwere not possible earlier. But as once remarked by Albert Einstein: “our technology has exceeded ourhumanity.”9

have made astute observations regarding unethical behaviour of some clinicians. Similar experiencesof the medical students have been reported. (Hicks, 2001)
To conclude, the major emphasis from this study is on the need of the internees to have a formal ethics
curriculum and the importance of the hidden curriculum in teaching of ethics.

References
Hicks, L.K. et al. 2001. Understanding the clinical dilemmas that shape medical students’ ethicaldevelopment: questionnaire survey and focus group study, British Medical Journal, Vol. 322, pp. 709-10.

10Asia-Pacific Perspectives on Bioethics Education

Michael, S. 1995. The Forgotten Curriculum: An argument for Medical Ethics Education, Journal American
Medical Association, Vol. 274, pp. 768-69.

Development of case study materials for teachingresearch ethics*
Juraporn Pongwecharak, Ph.D.
and Siriporn Krittathanmakul,
M.Pharm.,
Prince of Songkla University,
ThailandBackground

Universal ethical principles are: 1) respect for person autonomy; 2) beneficence; 3) non-malificence; and4) justice. Translating the principles into research conduct necessitates informing potential participantsof research details with adequacy and clarity so they can make decisions on their own whether or not
to participate in research (principle 1); protecting participants from harms incurring from research,
including minimizing the risks as well as balancing the risks and benefits gained from research (principles
2 and 3); and even or fair recruiting of potential participants so as not to put burden on a particulargroup of population in research (principle 4).
Various ethical guidelines in research involving humans issued by both local and internationalorganizations are available. All conform to the universal ethical principles above. In the USA, researchers
receiving federal grants are eligible to proceed with their research only after they attend a course inresearch ethics organized by their institution.
The School of Pharmacy, Prince Songkla University formed its own ethics committee to do ethicalreviews of research involving humans in 2001. Research ethics was included as a subtopic in researchmethodology for graduate students in the school, and the courses began in 2002. The aim of the topic
is to stimulate awareness and recognition of the importance of ethical conduct in research involving
humans. It is also expected that this would enable students to ethically conduct their research as part oftheir degree. Only three hours from a total of 45 hours is allocated for the research ethics topic.
Teaching is mainly by means of discussion, sharing points of view and assignment. There is no scoring or
pass/fail but the students are required to participate in the class in order to complete the credit earnedin research methodology. The assignment is based on drafting an information sheet inviting potential
subjects to participate in their planned study.
Creating awareness of ethical aspects in research involving humans may be acquired by studying real
or real-like situations rather than by lectures. Students should have an opportunity to ponder anddistinguish between ethical and unethical research conduct. Several studies showed teaching ethics
via small group discussion (Sponholz, 2000; Rosenbaum, 2003; Utaipan, 2003) and employing casescenarios presenting ethical dilemmas (Latif, 1999) increased the individual’s ethical sensitivity andtheir moral reasoning skills. Furthermore, a study indicated that moral development in adults can bechanged by means of education (Rest, 1986) although their prior experiences, background, attitudes
and beliefs may affect perception of ethical issues and the way of solving them.
Our students were assigned to read some ethical guidelines in research such as that of the World Medical
Association “Declaration of Helsinki”, WHO International Conference on Harmonization (ICH), the US
National Institute of Health (NIH) “Belmont report” (USA) and the Thai Food and Drug Administration* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

Health sciences research, especially in medicine and pharmaceutical sciences has contributed
substantially to drug development, assurance of their efficacy as well as the safety of use in humans.
While the body of knowledge and application of research methodology is a means to successful
research, ethical conduct in research must be in parallel thus “doing good” is achieved by doing rightfrom the start.

11

Thai translated version of the ICH guidelines. Other media for discussion included two films raising
ethical dilemmas in clinical research and profession practice, respectively; a video series of protecting
human subjects (1985) produced by the US National Institute of Health and the US Food and Drug
Administration; and case studies representing ethical dilemmas from two books by Coughlin et al (1997)
and Penslar (1995). The teacher acts as a facilitator to stimulate thinking, argument and discussion.
However, all tools for teaching were from Western examples. There is a need for the tools in the Thaicontext, thus this project was developed to produce Thai case studies presented with ethical dilemmas
in research, to be a tool for teaching research ethics in health sciences. It was also expected that thecases will be distributed for others to use as they see appropriate.

Methods

12

Asia-Pacific Perspectives on Bioethics Education

Individual interviews with researchers (N = 9) in various research fields involving human subjects, as wellas group interviews with healthy volunteers (N= 10). In phase one drug studies were conducted. Twointerviewers were used. Each researcher was approached via phone. They were informed of the purposeof the project and what we required from them. A further appointment was made for an interview ifthey agreed. In the interview for both researchers and volunteers, a leading open-question was used,i.e., “from your experiences on research of humans either directly or indirectly, had you encounteredany ethical issues?” The interviewers handed out documents with the contents of the interview, withor without tape-recordings. Interviewers were allowed to ask further questions regarding other ethicalissues which were not brought around by the interviewees following the leading question. The estimatedtime for the interview was 45-60 minutes.

Results
As a result, five case studies were written based on content drawn from interviews. All presented an
ethical issue which might be obvious or might be unclear prompting a further query. The narrative casestudies were presented in the appendix of this paper. It should be noted that questions for discussion
at the end of each case study were added after the cases were pilot-tested in a number of graduate
students. A summary of ethical issues pertaining to the five cases, with reference to the three ethicalprinciples previously mentioned, were as follows.
Case study one: Study of efficacy of herbal-extract dermatological product in HIV (+) patients
Issue one: Recruiting volunteers into the research (Ethical principle three)
Targeting HIV (+) patients to be recruited was biased as researchers intended to select only agroup of patients having a positive attitude towards the use of herbal remedies. Researchers
had a biased assumption that the group would not decline to participate in the research. In
recruiting, everyone eligible, i.e., HIV (+) patients with a specific skin condition should havean equal opportunity to participate. This was also not to put a burden on a particular groupof patients. Whether or not they accepted to be part of the study is another essential process
not related to the research method. It was also not a clinical characteristic in which the herbal
product was to be tested.
Issue two: Informing of alternative choices (Ethical principles one and two)In the informed consent process, the patients must be told about other available alternatives fortreatment of the skin condition if they choose not to take part. In addition, it should be madeclear that if the herbal product fails, what are the plans for those who did not respond?
Issue three: Confidentiality of data (Ethical principles one and two)
The study population is HIV (+) which should be kept confidential to avoid a social risk (social
stigma) from disclosure of the HIV status to other parties not involved in the study.

Case study two: A pharmacokinetics study of a sustained-release antihypertensive agent in healthy
male volunteers.
Issue one: Safety or risk to volunteers (Ethical principles one and two).
Potential volunteers must be informed of the possibility of blood pressure reduction associatedwith the drug being tested. Researchers should also present previous findings pertaining to theeffect of blood pressure reduction in normo-tensive individuals and planned safety measures,i.e., the volunteers must be confined to a laboratory area which is fully equipped with emergency
kits and qualified health personnel.
Case study three: Study of mutant gene associated with cervical cancer in Thai females.
Issue one: Use of existing biological specimens of individuals for research purposes (Ethicalprinciple one).

Most importantly, the owners of the specimen acknowledged that providing the cervical cellsample was part of routine screening in healthcare, but they were not aware of further use of thespecimen for research purposes.
Issue two: Researchers’ responsibility after the study (Ethical principles one and two).
This issue is a consequence of issue one - whether or not the researcher sought permission fromthe women who informed them of the purpose and prepared advance consent to be notified of
the results of the mutant gene.
In anticipation of the results of the study and the fear that it might impact on women’s health in
the future, how do researchers plan to notify women who owned the specimen, and what kindof surveillance would they plan or would they opt not to report back to the women? What is therationale for these actions?
Case study four: Efficacy of a simplified antiretroviral regimen in prevention of maternal to childtransmission of HIV.
Issue 1: Researchers’ responsibility after the study (Ethical principles two and three).
Potential volunteers are pregnant with HIV (+). These people may autonomously take part in the
study with the hope of getting antiretroviral therapy (the study group).
Babies born from mothers, especially those in the placebo group, could have been infected with
HIV. What was the plan for both mothers and their child after the end of the study? Or was thisplan considered to be beyond the scope of the research?
Issue two: Placebo use and standard of care (Ethical principles two and three).
The study compared the active study drug (simplified antiretroviral regimen) against placebos
instead of standard treatment (full antiretroviral regimen), because the standard treatment was
not the standard in the country. Even if it was available in the country, most HIV infected persons
would not be able to afford it. Therefore it appeared that the context of the country determines
what is to be considered ethically or unethically acceptable.
Issue three: Confidentiality of data (Ethical principles one and two).
The study population is HIV (+) which should be kept confidential to avoid a social risk (social
stigma) from the disclosure of the HIV status to other parties not involved in the study.

Asia-Pacific Perspectives on Bioethics Education

Although researchers asked for permission and informed the women of the purpose of collecting
a blood sample, they did not do the same with the cervical cell specimen. The point of viewmight be that the cell specimen already existed for cervical cancer screening purposes, with noneed to collect more samples for research purposes.

13Case study five: Survey of community pharmacist’s dispensing antibiotics for treatment of sorethroat or diarrhoea.
Issue one: Individual right and privacy (Ethical principle one)
This case involved “secret shopping” as well as “secret tape recording” in research methodology
so actual behaviour was obtained and the objective achieved. However, this process violated
individual privacy. Weighing the impact of study or the benefit gain against the need to violate
individual rights and privacy should be considered.
Issue two: Distribution of the study results (Ethical principles one and two)
Researchers should present how they intended to report the overall findings. Notification of thefindings to the pharmacists being studied is basically necessary for the change toward dispensing
behaviour to happen. Otherwise, the study would be of no value.

Pilot -testing the cases

14

Asia-Pacific Perspectives on Bioethics Education

All the five case studies were tested in a group of six graduate students at the school (female four, maletwo). Four had already experienced the research ethics course.
Each read the cases independently. Following the reading, they were asked to evaluate the caseregarding ethical issues by answering a question in a form attached with each case. The question was:“Did you feel there is any particular ethical issue in the case? If so how would you rate their importance?”
They were told there could be more than one issue and a scoring of one to five represented the degreeof importance from the least to the most important. The findings were presented in Table one.
Table one: Graduate students’ perception of ethical issues and their importance scores in the fivecase studies
Case study

No 1: Study of efficacy of herbalextract dermatological product inHIV (+) patients.

No 2: A pharmacokinetics study ofa sustained-release antihypertensive
agent in healthy male volunteers.

No 3: Study of mutant gene associatedwith cervical cancer in Thai females.

Ethical issue (s) perceived

Average score (N)Providing clear information to the potential
volunteers that it is a test of herbal product4.5 (4)

Risk of taking the herbal product4.25 (3)Asking patients not to use other concurrent
treatment for the condition being studied.

3.5 (2)

Not perceiving any ethical issue.

- (1)Risks or adverse effects associated with the study
drug.

4 (3)

Recruitment of volunteers from a particular grouplikely to accept the study.

4 (2)Written inform consent rather than oral consent.

4 (6)Making use of existing biological specimen forresearch purposes without permission is violating
the individual’s right.

5 (2)Confidentiality of results of mutant gene.

4.5 (2)

Notification of result of mutant geneindividual.

to

4 (1)

No 4: Efficacy of a simplified
antiretroviral regimen in preventionof maternal-to-child transmission ofHIV.
No 5: Survey of community
pharmacist’s dispensing antibiotics
for treatment of sore throat or
diarrhoea.

Placebo use and outcome of baby born frommothers receiving placebo.

5 (6)Informing the mothers that it was a study notroutine care and that there was chance of getting
placebo.

4.7 (3)

Secret tape-recording and study without awarenessof the pharmacists.

4.5 (6)

Report of the findings without disclosure ofidentities of the pharmacists.

4 (1)In the academic year 2006, the five cases were used, along with other tools, to teach research ethics at
the graduate level. The responses from students observing the discussion environment and student
evaluation was obtained. It is believed that the cases could be used for the same purpose in otherallied health sciences students, although there were courses or programmes designed for researchers
in specialist fields such as psychiatry (Rosenstein et al., 2001) and emergency medicine (Moskop et al.,1990).
Finally, research ethics should be set as a separate seminar course so that there is sufficient time tocover every aspect of research ethics, for example, research in vulnerable populations; genetic research;conflicts of interest; research sponsorship; and scientific misconduct. It deserves to be a multidisciplinary
course in the area of health sciences.

Acknowledgements
The project is part of the ASEAN-EU LEMLIFE project at the Faculty of Arts, Chulalongkorn University,
Bangkok. Special thanks are due to the researchers and past volunteers who gave their time forinterviews. Their participation made the whole project possible.

References
Coughlin, S.S., Soskolene, C.L. and Goodman, KW. 1997. Case studies in Public Health Ethics. American
Public Health Association. Washington DC.
Latif, D.A. 1999. Using ethical dilemma case studies to develop pharmacy students’ moral reasoning.
Journal of Pharmacy Teaching, Vol. 7, pp. 51-66.
Moskop, J.C., Mitchell, J.M. and Ray, G. 1990. An ethics curriculum for teaching emergency medicine
residents. Annals of Emergency Medicine, Vol. 19, pp. 187-92.
Penslar, R.L. 1995. Research ethics; Cases and Materials. Indiana University Press, Bloomington andIndianapolis.
NIH. 1985. Protecting human subjects [videocassette]. National Institutes of Health and the Food and Drug
Administration.
Rest, J.R. 1986. Moral development in young adults. In: Mines RA and Kitchener KS (eds.) Adults cognitive
development: Methods and models. New York: Praeger, pp. 92-111.
Rosenbaum, J.R. 2003. Educating researchers: Ethics and the protection of human research participants.
Critical Care Medicine, Vol. 31, pp. 161-6.
Rosenstein, D.L., Miller, F.G. and Rubinow, D.R. 2001. A curriculum for teaching psychiatric research

Asia-Pacific Perspectives on Bioethics Education

The pilot-testing showed that for each case study, each individual student was aware of an ethical issue
differently in both seeing it as an ethical matter and its importance. They did not always see the same
points as previously summarized for each case. On the other hand, some raised other different issues
they considered an ethical one. In fact, any reader may see other extra ethical issues or raise a different
ethical question. Such diversity would be a good vehicle for discussion or argument.

15

bioethics. Biological Psychiatry, Vol. 50, pp. 802-8.
Sponholz, G. 2000. Teaching scientific integrity and research ethics. Forensic Science International, Vol.
113, pp. 511-4.
Utaipan, P. 2003. The effects of discussion of moral dilemma on moral competence among pharmacy
technician students and dental nurse students. Minor Thesis, Faculty of Pharmaceutical Sciences, Princeof Songkla University.

Appendix
Case one: Study of efficacy of herbal-extract dermatological product in HIV (+) patients

16

Asia-Pacific Perspectives on Bioethics Education

It has been documented in Thai folk medicine recipes that a mixture of the dried bark of a tree and alime solution when applied to a rash can improve or resolve the symptoms. In herbal medicine research,
it is common to obtain an extract of active substance(s) and test it on rash-induced mice. Regarding the
mixture, the test results were satisfactory. A skin product containing the extract was then developed.
The team wanted to test if the product worked on HIV (+) patients in which skin rashes were commonand no specific treatment was available. HIV (+) patients’ care teams at three public hospitals, whichwere known for their policy to promote the use of herbal medicines were approached. The hospitals
had anonymous outpatient clinics catering for HIV (+) patients. Modes of caring were divided to thoseof western medicines and those of herbal medicines for which patients voluntarily opted.
The study was single blind randomized placebo control. Patients in the herbal medicine clinic werechosen as they already accepted the use of herbal medicines. The patients were randomized to receive
either a placebo skin product or a test product containing the bark extract. Both products were similarin their appearance and colour. The subjects were advised to apply the product to the affected area
three or four times a day. They were scheduled to a follow up on a weekly basis for the first month, thenmonthly for a total of six months. Outcomes measured were the patient’s self reporting of their rash/pruritus status. A total count of papules, as well as the general appearance of the skin before (baseline)
and after the treatment were evaluated. The subjects were asked not to use other products for skin relief
during the study.
Questions/ points for discussion:• If you were a member of the ethics committee, would you query researchers?
• Would you view the study differently if the study population were not HIV infected?
• The ethics committee suggested researchers recruit all HIV patients infected with skin ailments as
specified in the inclusion criteria.

Case two: A pharmacokinetics study of a sustained-release antihypertensive agent in healthy malevolunteers
In order to get approval for marketing, a domestic pharmaceutical company who manufactured
a sustained release tablet of an antihypertensive agent had to show the FDA the comparative
pharmacokinetics of the drug against the original product produced by the Innovate pharmaceuticalcompany. The company provided a study protocol which required 20 healthy adult male volunteers. The
research institution sought subjects from nearby universities. Those who were interested in participatingwere informed of the details. After the informed session, they were asked to sign a consent form to takepart in the study on the same day. The volunteers fasted for eight hours before taking a single drug
orally and their blood sample was collected at pre-specified times during a 24 hour period. After thewashout period, the volunteers repeated the process with the other product. During the study they
were allowed to take leave but had to be back in time for the next blood collection. A research assistant
took care of the volunteers and collected their blood samples.

Questions/ points for discussion:• If you are interested in taking part, what would you like to know first from the researcher?
• If this study was carried out on people with high blood pressure, would you view the study differently?

Case three: Study of mutant genes associated with cervical cancer in Thai females
A research group wanted to study the inherited risk factor for cervical cancer in Thai females. They needed
to inspect DNA from blood samples and cervical epithelial cells to verify the presence of a mutant gene.
The biological specimens of a large number of women coming for the pap smear test would be neededas the results were to be reported at a population level.
During the study, the investigator brought cervical epithelial cells from the pap smear to further examine
the mutant gene. Permission was sought and the women were informed of the reason for collecting
the blood samples, i.e., to check for abnormal genes which might be associated with an occurrence of
cervical cancer.

• If you were among the women, would you agree to the blood collection?
• Why and why not would you think researchers could take the specimen sample for further examination
for a possible mutant gene?
• If the study found a mutant gene in an individual woman, is it the researchers’ responsibility to notify
women of the results?

Case four: Efficacy of a simplified antiretroviral regimen in prevention of maternal to childtransmission of HIV
Researchers wanted to run a study to find out if a simplified regimen of antiretroviral had a comparable
efficacy to a full standard regimen in the prevention of mother to child transmission of HIV.
The trial was randomized double blind placebo control carried out at various gynaecology clinics atlarge hospitals. By randomization, the pregnant women might get the study drug or receive nothing(placebo). Informed consent was given. Participants had to come to the hospital to receive the treatment
twice before delivery, and for the baby after birth. All expenses were compensated.
Questions/ points for discussion• The study should be conducted in countries where standard treatment was available so the placebo is
not used.
• Ethical principles depend on local context or circumstances thus they cannot be universal.
• Is it the researchers’ obligation to be responsible for the health of women and their child especially in theplacebo group after the end of the study?
• Would you view the study differently if the findings turned out to be; the simplified regimen proved
to be effective in the prevention of HIV transmission from mother to child thus it become standard
treatment in the country and other developing countries or if the simplified regimen failed.
Case five: Survey of community pharmacist’s dispensing antibiotics for the treatment of sorethroats or diarrhoea
Injudicious use of antibiotics leads to bacterial resistance. In Thailand, community pharmacists can,with their discretion, dispense antibiotics to a client after a thorough history research of his/her

Asia-Pacific Perspectives on Bioethics Education

Questions/ points for discussion

17

symptoms. Researchers employed the “secret shopping” method in their study. A group of volunteers
acted as shoppers in need of antibiotics for sore throats or other ailments. Community pharmacists
under investigation were blind to the study. As soon as each trained client finished their job, they had to
document details of the community pharmacist’s comments and the medications dispensed for them.
In order to make sure the clients did not miss anything for data collection, the researchers prepared asmall tape-recorder for everyone to record the conversation while in the pharmacy. It could be hidden
inside their clothes without being noticed. The recorded contents were transcribed onto the datacollection form.
Questions/ points for discussion

18

Asia-Pacific Perspectives on Bioethics Education• The study did not require ethical approval as it is impossible to inform a community pharmacist about
the study otherwise the study could not meet its objective. If you were a community pharmacist being
investigated and you accidentally found out that you were being tape-recorded, what would be yourreaction? What action would you take?

Bioethics education in tertiary settings: The Universityof Malaya experience*
Maude Phipps, Ph.D.
The University of Malaya,
Malaysia

Introduction
Biotechnology and biological sciences have emerged as the focal points in the development agendas
of many Asian countries. Inherent within these agendas are activities related to the promotion andpermeation of biotechnology and molecular biology into agriculture, manufacturing, medicine,
education, research and development and so forth. Malaysia, a rapidly developing country with apopulation of some 28 million inhabitants, has not been left behindArcheological findings have revealed the existence of human remains in Neolithic settlements, dated
between 10,000 to 15,000 years ago in north Malaysia. It has been generally accepted that land based
migrations of Homo sapiens to more southern regions and the Australian continent occurred throughthe Malay peninsular some 50,000 years ago1,2. In terms of recent history, Malaya was declared an
independent country from British colonial rule in 1957. In 1963, Malaysia was formed, comprising thePeninsular (West) and Sabah and Sarawak (East). The country is run based on parliamentary democracy.
The legal system incorporates civil law, derived from British elements, and aspects of Syariah laws for
Muslims.

Biodiversity
Malaysians are a heterogeneous population. Our present culture and way of life, not unlike in manyother countries, have been influenced by Hindu, Chinese, Islamic, Western civilization and thought.
Presently, Malays, Chinese, Indians, Eurasians, Indigenous people and other communities make up ourunique linguistic and cultural heritage and way of life.
While the present constitution enshrines the right of religious beliefs for non-Malays, Islam is the official
religion and is practiced by Malay community who form approximately 55-60 per cent of the population.
Buddhism, Christianity, Hinduism, Sikhism and other religions and beliefs, are practiced relatively freely
and peacefully. On the whole, we have a “salad bowl of different people”, the majority of whom place
peace, tolerance and economic prosperity high on their agenda. This concept is more applicable rather
than the proverbial “melting pot”, which to my mind does not exist in the true sense of the word.
Although relatively small in terms of landmass, Malaysia has been officially designated as one of the 17“mega-biodiversity” countries3. It has an abundance of natural resources, flora and fauna. Petroleum,
timber, and other commodities continue to fuel the economy. In the quest to reach a “developed
country” status, in accordance with promoting better quality of life to citizens in both rural and urban
areas, governmental and private sectors, continue to fund and encourage developments in education,
healthcare, science and technology. At the same time, there is the awareness that in line with rapid local
and global developments, ethical, legal and social issues are important and should not be neglected.

Bioethics programmes
Bioethics is entirely relevant, more so in a multicultural and multi-religious country. Global developments
in socio-economics, biodiversity discovery and depletion, scientific and technological advances,* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

The Local Setting

19

improved therapeutic and reproductive options, genetically engineered life forms, conservation and so
on, necessitate active and informed responses from both developed and developing nations, based on
not only balanced but also factual perspectives.
Efforts are being made in educational and other establishments, to promote bioethics awareness andeducation. In 2005, 17 public universities, and more than 30 private/joint venture universities/higher
educational establishments are listed in Malaysia. The University of Malaya (UM), the first university
in the country, has its roots in the founding of the King Edward College of Medicine in 1905. In thisour hundredth year, the faculty of medicine still runs the largest number of undergraduate andpostgraduate biomedical programmes in the country. In terms of biomedical research, it is essential
to ensure responsibility, quality and accountability. Multidisciplinary and collaborative approaches are
utilized in addressing questions pertinent to health and wellbeing.
In 2003, with the ethos of producing academically able, capable and ethically conscious graduates, theuniversity initiated compulsory moral and professional ethics courses for all undergraduate programmes,
the specifics of which were addressed at the faculties of science, law, arts, and many others, according totheir own systems and requirements.

20

Asia-Pacific Perspectives on Bioethics Education

While the focus of most teaching programmes in biomedical sciences, clinical medicine, nursing andpharmacy, remains on delivering medical, paramedical and professional training from lab bench
to bedside, biomedical ethics is viewed as an integral part of practice. The existing medical ethics
committee reviews research projects, treatment regimes and other matters. Biomedical ethics is now anessential component in the various teaching and research programmes.

Courses and approaches at the University of Malaya
The following are some bioethics based courses taught in UM:• Biomedical Ethics;• Professional Codes of ethics for Clinician, Nurses, Pharmacists and Health Care Professionals;• Ethics of Science and Technology, Contemporary Bioethics;• Medico-Legal Laws and Practices
The Biomedical Ethics course is broad based rather than in depth, limited by time and available academic
staff. Topics covered include origins and philosophies in ethics, ethical research practice on humans andanimal subjects, data integrity, clinical trials, assisted reproductive technologies, xenotransplantation,
human genetics, telemedicine, therapeutic and reproductive cloning, intellectual property andpatents.
The aims are to expose, inform and train, and also to help the educators gain insights into the thoughts,
practices and minds of our students through their responses. Apart from didactic teaching from texts,
we also incorporate interactive sessions, where groups of students are challenged with scenes andsituations in daily life, journal articles, newspaper clippings or reports of local and global events. For
example, we have used articles related to the Dec 2004 tsunami disaster, “optional weapons training” inthe local national service programme, the ban on smoking in public places and “anti-cancer tomatoes
and eggs” reports (in references). In terms of assessment, marks are awarded via quizzes, spot tests,
presentations and a written examination.
In the words of Lao Tzu, “the journey of a thousand miles begins with a single step”. Where Malaysia isconcerned, we may well be at the beginning of the very long road of bioethics awareness and education.
In this journey, the commitment and participation of local and international experts and organizations,would help tremendously towards the better training and practice in bioethics. Comprehensive
programmes that address education, training and capacity building at various levels are essential. It isimperative that efforts must be made to generate not only knowledge but also ethical thought, respect
and love for life and empowerment.

Acknowledgements
Friends and colleagues in Malaysia : Anuar Zaini, Hj. Azizuddin, Esmund Yeo, Khalifah Sidik, Mohd.
Ibrahim, Rohani Arshad, Patrick Tan, Wong Yut Lin, Yasmin Othman, Sharan Kaur, Siti Nurani, Zahurin
Mohd., Suzainur Kulop, Suzita Mohd., and students, without whom the courses would not be. Darryl
Macer and colleagues at the Eubios Ethics Institute and UNESCO. Abdullah Daar, Tikki Pang, Koh Chong
Lek, John J. Bosco, and KK James. The University of Malaya and the Ministry of Science Technology andInnovation, Malaysia.

References
Archives, National Museum of Anthropology, Lenggong, Perak, Malaysia.
Baer, A. 1999. Health, Disease and Survival. A biomedical and genetic analysis of the orang asli of
Malaysia.
Verela, I. Jr. 2003. Special Report: ‘Rescuing ASEAN’s Mega Biodiversity’, ASEAN secretariat. http//
aseansec.org/12781.htm

Asia-Pacific Perspectives on Bioethics Education

Biomedical Science Programme Guidebook. 2005. Faculty of Medicine, University of Malaya.

21

Ethical views of first-year medical and nursing
students in a joint bioethics course*
Noritoshi Tanida, M.D.
Yamaguchi University School of
Medicine, Japan

22

Asia-Pacific Perspectives on Bioethics Education

Introduction
Both health care providers and receivers are now involved in medical decision-making, and they often
hold conflicting ethical views. It is predominantly nurses who are confronted with the claims of thepatient and/or family in Japan, while many doctors simply ignore the existence of their wishes (Konishi,
1998). In the multidisciplinary team approach, the sensible contribution of all healthcare professionals
is a prerequisite. In particular, close collaboration between the doctor and nurse is essential to thepatient and family, regardless of the traditional positions of doctor and nurse. A means of achieving
this collaboration and lessening the tension between doctor and nurse may be participation in joint
ethics courses for medical and nursing students (Fagin, 1992; Tschudin, 2000). Because professionalsocialization starts with the decision to be a doctor or a nurse, opinions on ethical issues in the earlydays of professional training may be important for faculty education. In previous work, the opinions of
medical and nursing students on ethical issues in general and on organ donation have been studied,and some differences were observed (Kurtzman et al., 1985; Peter and Gallop, 1994; Nolan and Smith,
1995; Cantwell and Clifford, 2000). These differences may depend on cultural tradition and other social
factors. The present study examines differences in the views of medical and nursing students withregard to certain ethical issues.

Methods
Bioethics is a compulsory component of the first-year medical and nursing courses at Yamaguchi
University, and in the first semester in 2004, 85 medical and 53 nursing students attended this course
jointly (Tanida, 2005). The lecturer discussed the pros and cons of the topics without attempting toimpose “right answers”. At the end of each lecture, the students were asked to give answers to questions
on the topics covered, with a “yes” or “no” response and a comment.
Question one, a specific question, was taken from an actual case in the United States (Gottlieb, 2003) inwhich a prisoner on death row became mentally ill. Because a mentally ill man cannot be executed, theauthorities asked a doctor to treat the patient, and the doctor refused. Students were asked to answer
the question: “Would you treat this patient?” The decision of the Supreme Court to proceed with theexecution was subsequently disclosed to the students and discussed the following week.
Question two related to the American legal doctrine of informed consent. In the case study, a patientdeveloped toxic epidermal necrosis syndrome in response to a drug prescribed by a doctor, andeventually died. The family of the patient sued the doctor, claiming that the doctor should have drawn
explicit attention to the possibility of such a serious drug reaction, so that the patient was alerted andcould take immediate measures if the problem eventuated. The follow-up story was presented thefollowing week, and implications of the court decision were discussed.
Specific questions three and four referred to a claim by the family of a patient who died as a result of
a complication during surgery. During an emergency cholecystectomy, a bile duct was injured, anddespite repair and intensive treatment, the patient died. The family of the patient sued the surgeon on
the charge of manslaughter. The mortality rate for elective cholecystectomy is a maximum of one percent, while the mortality rate for common bile duct damage during surgery is about 20 per cent. Thesefigures had been explained to the patient and family under informed consent. There was no obvious
negligence, as the surgeon had taken all necessary measures during surgery. The Good Samaritan Law* Paper first presented at the joint UNESCO:UNU-IAS Roundtable on Japanese Perspectives on Bioethics Education heldin Yokohama, Japan in February, 2007

was explained to students before presenting this case study.
The open questions were, “When does human life begin?” and “Which issue in bioethics is of the mostimportance?” This last question was asked at the conclusion of the course. The statistical analyses
employed SPSS 11.5 J. All p values were two-tailed. Statistical significance was suggested at p<0.05 andtendency at p<0.1.

Results
The background profiles of the students were described elsewhere (Tanida, 2005). Table one summarizes
the responses to the specific questions. Medical students answered in the positive to treating acondemned mentally ill man more frequently than nursing students, and male students approved more
frequently than female students overall (77 per cent versus 65 per cent, p=0.10). The logistic regression
analysis indicated that faculty contributed significantly to the attitudes of students on this issue (Table
two). Almost all students considered this a difficult decision for health care providers. Some comments
by students who answered “yes” were: “Treatment is an obligation of the doctor.” “It is assumed thatthe mentally ill person wants to be treated.” “What happens after treatment is not an issue.” and “Thelaw and the request of the authorities should be respected.” The reason for answering “no” was almost
exclusively, “I cannot assist in killing a man, even if there is a professional obligation to treat.”

Medical students
number (%)

Nursing students
number (%)

p value

1. Treat a mentally ill man to make him fit for execution?
Yes

65 (76)32 (62)No

20 (24)20 (38)0.06

2. Support the American legal doctrine of informed consent?
Yes

69 (85)46 (92)No

12 (15)

3 (6)

0

1 (2)

Not decided

0.14

3. A criminal law suit against the responsible surgeon is reasonable?
Yes

67 (80)47 (90)No

15 (18)5 (10)

Not decided

2 (2)

0

0.20

4. The surgeon should be prosecuted for manslaughter?
Yes

41 (49)35 (67)No

43 (51)16 (31)0

1 (2)Not decided

0.03

On the issue of informed consent, most students supported full disclosure of medical information (Tableone). However, male students were less supportive than female students (86 per cent versus 91 per cent,p=0.39). Students in favour of full disclosure commented that any possible serious drug reaction should
be explained to the patient before treatment, even if its occurrence rate is extremely rare. Students
against full disclosure considered that such a small possibility of a drug reaction is clinically insignificant,and therefore should not come under the general rules of informed consent.
Most students thought that a criminal law suit against the surgeon in this case was reasonable (Tableone). Male students agreed less frequently than female students (76 per cent versus 91 per cent, p=0.03).
Both faculty and gender were contributory factors to students’ attitudes on this issue (Table two). Fewer

Asia-Pacific Perspectives on Bioethics Education

Table one. Response of students to specific questions

23

medical students thought that the surgeon should be prosecuted for manslaughter than did nursing
students, but the percentages for males and females were very similar (55 per cent versus 57 per cent,p=0.57). Faculty contributed significantly to the degree of support for the charge of manslaughter (Table
two). Comments indicated that sympathy for the patient’s family was a major reason for approvingof criminal law suits against the responsible surgeon, and included, “the consequence is of mostimportance,” “no excuse for loss of patient’s life resulting from surgeon’s action” and “the responsible
surgeon should be punished as in traffic accidents”. Students who disapproved commented that “it is
too harsh to punish the surgeon who did his best”, “informed consent was obtained from the patientand family, and the family should have understood and accepted the risk of such a complication prior tosurgery” and “medicine is by no means 100 per cent successful, the surgeon’s effort should be appraised”.
Students who answered “undecided” commented that how the surgeon and hospital dealt with thecase after the incident was critical in deciding whether criminal prosecution was reasonable.
Table 2. Odds ratios and 95 per cent confidence intervals in logistic regression analysis
Odds ratio (95% confidence interval)

p value

Treat a mentally ill man to make him fit for execution?
Faculty (medical=1.00)

0.50 (0.22 - 1.11)

0.09

Gender (male=1.00)

1.06 (0.33 - 3.44)

0.91

24

Asia-Pacific Perspectives on Bioethics Education

A criminal law suit against the responsible surgeon is reasonable
Faculty (medical=1.00)

3.27 (1.10 - 9.58)

0.03

Gender (male=1.00)

7.69 (0.90 - 58.8)

0.06

The surgeon should be prosecuted for manslaughter
Faculty (medical=1.00)

1.96 (0.90 - 4.16)

0.09

Gender (male=1.00)

0.64 (0.24 - 1.73)

0.39

The answer “yes” was scored as the dependent variable, and “undecided” was counted as “no”

Table three summarizes the responses to the open questions. Similar percentages of medical and nursing
students thought that human life begins at fertilization. Twelve per cent of the nursing students thoughtthat life started at implantation. The most important ethical issue was brain death/organ transplants for
medical students and assisted reproductive technology for nursing students, followed by the issue of
informed consent in both students. Many students commented on the importance of studying ethics
in medical and nursing schools. In the discussion the following week, students were surprised at thedifferences in their opinions.
Table three. Responses of students to open questions
Medical students
number (%)

Nursing students
number (%)

First encounter of parents

1 (1)

2 (4)

Fertilization

54 (64)33 (63)p value

Life starts at/when:

Implantation

5 (6)

6 (12)

Human body shape

4 (5)

1 (2)

Abortion impermissible

4 (5)

2 (4)

Delivery

4 (5)

4 (8)

Foetus becomes conscious

4 (5)

1 (2)

Mother realizes pregnant

3 (4)

2 (4)

Other

5 (6)

1 (2)

0.715

Most important ethical issue:
Brain death/organ transplant

15 (18)6 (11)

Assisted reproductive techn.

10 (12)12 (23)Euthanasia

12 (14)5 (9)Terminal care

7 (8)8 (15)

Malpractice

8 (9)

5 (9)

Gene technology

6 (7)

1 (2)

Informed consent

14 (16)

11 (21)

Communication

9 (11)

4 (8)

0.399

Others4 (5)1 (2)The issue of truth disclosure was included in informed consent.

The results indicate a similarity of ethical views in some areas and differences in others. For example, themajority of students favoured treating a condemned man for mental illness to expedite his execution,although almost all students commented on the difficulties of the decision for health care providers.
Many students acknowledged the importance of esteem for the traditions and culture of law insociety, which suggests agreement with the Japanese position of maintaining capital punishment, as
in some States of America. The students’ attitudes on this issue differed by faculty but not by gender.
The less affirmative attitude of nursing students towards playing a role in an execution may derivefrom their professional commitment to caring for patients, as exemplified by their greater support
for organ donation compared with medical students (Cantwell and Clifford, 2000). The absence ofgender difference in a matter associated with capital punishment might be predicted from a findingof no relationship between gender and a “justice” orientation in ethical reasoning among healthcare
professionals (Kuhse et al., 1997).
Students were predominantly critical of the surgeon responsible for a patient’s loss of life. Japan has along history of punishment for medical misconduct, dating back to the first written law (Taiho-Ritsuryo)
in the eighth century (The Japan Academy, 1957). Nurses are not exceptional in this regard, as the efforts
or good intentions of health care providers on behalf of patients are not taken into consideration in
malpractice suits in Japan. In Western culture, health professionals are protected by the Good Samaritan
Law from liability for malpractice in emergency situations, so far as there is no gross negligence inpractice. Although the Good Samaritan Law and its implications in medicine had been explained justbefore this question was asked, none of the students mentioned it specifically in their comments. Thelong tradition of punishing the doctor for any errors, which is considered significant for patient safety inJapan, may be the reason for this orientation. Even in the United States, where the Good Samaritan Law
has been enacted, medical errors are not openly discussed, so that errors are under-reported (Volpp etal., 2003). In Japan, reporting one’s own errors establishes liability for criminal charges, so that doctors
and nurses hesitate to report them. In such circumstances, measures aimed at patient safety based onreported errors will be erroneous. Thus, a reasonable system which will encourage the reliable reportingof errors is still needed. This might be achieved by the separation of criminal and civil liability.
There was an epic decision made in 1996 regarding the doctor’s obligation to obtain fully informed
consent, when the high court overturned a district court decision and ruled that general warnings aboutrisk were not sufficient, and the doctor must explain every material risk, even if its rate of occurrence isextremely rare (Anonym, 1997). As the Supreme Court had already rejected “the professional standard”
as the criterion in malpractice suits, this decision of the high court is unlikely to be overruled by theSupreme Court. Although only decisions of the Supreme Court are effective as written law, Japanesejudges appear to have accepted the American legal doctrine of informed consent. It is apparent,
nevertheless, that Japanese medical culture has not accepted the obligation for informed consent.
However, although a minority of students supported the traditional paternalism, the large majority of
medical students appeared, in this study, to have accepted the American rule of informed consent.

Asia-Pacific Perspectives on Bioethics Education

Discussion

25

26

Asia-Pacific Perspectives on Bioethics Education

The responses to the open questions indicate that students’ attitudes are influenced by various cultural
factors. For example, Japanese eighth century law maintained that a human being comes into existencein the uterus when a human body shape has developed, that is, at approximately at four months
gestational age (The Japan Academy, 1957). This law is still in effect, as a death certificate is required fora miscarriage for later than four months gestational age. This law did not specify when life begins, and it
appears that the Japanese have accepted fertilization as the start of human life, presumably influenced
by Christian culture. The most important ethical issues nominated by the students in this study are
in clear contrast to those found in the UK, where the issues cited as most important were euthanasia
and abortion, with brain death/organ transplants coming last (Nolan and Smith, 1995). Presumably, theattitudes of students are influenced by the areas of intense debate in their respective countries.
The present study revealed areas of ethical differences between medical and nursing students at the very
beginning of professional education. This was a descriptive observational study; therefore contributing
factors for their ethical views were not sufficiently examined. Therefore, generalisation may be difficultfrom this single study, and information for other healthcare professionals is needed. Furthermore, it isimportant to see a long-term effect of such a joint course of ethics education. Nonetheless, the students
commented that knowing their counterparts’ opinions is valuable in enhancing mutual understandingon ethical issues. Knowledge of differences in the ethical views of medical and nursing students should
be incorporated in the design of professional training so that ethical sensitivities can be respected andfostered between medicine and nursing. It is hoped that joint participation of medical and nursing
students in ethics education will not only enhance their future collaboration but also improve patientcare. In this sense, it may be necessary to incorporate joint ethics courses for the upper student classes
and trainees of healthcare professionals.

References
Anonym. 1997. The case died of toxic epidermal necrosis syndrome after meningioma surgery where theattending doctor was liable to misconduct due to his failure to inform of explicit drug adverse reaction to
the patient for avoiding fatal consequence with prescribed drugs. Hanrei Jiho, Vol. 1591, pp. 44-54 (inJapanese).
Cantwell, M. and Clifford C. 2000. English nursing and medical students’ attitudes towards organ donation.
Journal Advanced Nursing, Vol. 32, pp. 961-968.
Fagin, CM. 1992. Collaboration between nurses and physicians: no longer a choice, Academic Medines,
Vol. 67, pp. 295-303.
Gottlieb, S. 2003. Murderer can be forced to take medication to become sane enough to be executed. British
Medical Journal, Vol. 327, p. 889.
Konishi, E. 1998. Nurses’ attitudes towards developing a do not resuscitate policy in Japan. Nursing Ethics;
5: pp. 218-227.
Kuhse, H., Singer, P., Rickard, M., et al. 1997. Partial and impartial ethical reasoning in health care
professionals. Journal Medical Ethics, Vol. 23, pp. 226-232.
Kurtzman, C., Block, D.E., Steiner-Freud, Y. 1985. Nursing and medical students‘ attitudes toward therights of hospitalized patients. Journal Nursing Education, Vol. 24, pp. 237-241.
Nolan, P.W. and Smith, J. 1995. Ethical awareness among first year medical, dental and nursing students,
International Journal Nursing Studies, Vol. 32, pp. 506-517.
Peter, E. and Gallop, R. 1994. The ethic of care: a comparison of nursing and medical students, Image
Journal Nursing School, Vol. 26, pp. 47-51.
Tanida, N. 2005. Ethical views of first-year medical and nursing students in a joint bioethics course, IgakuKyoiku (in Japanese).
The Japan Academy. 1957. The Japanese Medical History before Meiji Era, Vol 5. The Japan Academy, theJapanese Science History Publishing Committee ed., Nippon Ko-igaku Shiryo Center, Tokyo.
Tschudin, V. 2000. International reasons for joint learning and studying. Medicine Law, Vol. 19, pp. 409413.
Volpp, K.G.M. and Grande, D. 2003. Patient safety: Residents’ suggestions for reducing errors in teaching
hospitals. New English Journal Medicine, Vol. 348, pp. 851-855.

Bioethics education in Pakistan: challenges andprospects*
Aamir M. Jafarey, M.D., Ph.D. andSyeda Kauser Ali, M.D.
Centre of Biomedical Ethics andCulture, Pakistan

Bioethics is now regarded as an integral part of contemporary medical education across the World. Welldefined strategies have been developed and are in place for undergraduate as well as postgraduate
bioethics education.1 Continuous Professional Development approaches (CPD) have also been devised
to keep healthcare professionals abreast with emerging challenges to the multi-disciplinary field ofbioethics. It is, however, mainly reliant on contributions made by Western bioethicists, philosophers andtheologians that have been responsible for the recent development and popularization of contemporary
bioethics. Developing nations, particularly the countries comprising the Islamic bloc have largely takena back seat and have preferred to rely on “imported” bioethics. This is seen in conduct of CPD workshops
for which invited foreign faculty are flown in for a few days as well as in the development of bioethics
curricula for their students, for which they have turned towards foreign text books preaching unfamiliar
principles.
The situation in Pakistan is not different from the rest of the Islamic countries. There are 56 medical anddental colleges both in the public and private sector in the country. Although the Pakistan Medical and
Dental Council stipulates that bioethics should be taught as a mandatory course at the undergraduatelevel,2 evidence indicated that this is clearly not the case. According to a recent national survey by oneof the authors, only a minority (five per cent postgraduate and 39 per cent undergraduate institutions)have some bioethics teaching in their institutions. Eighty two percent of the postgraduate and 65
per cent of undergraduate medical institutions however expressed a desire to incorporate bioethics
education in their curriculum (unpublished data).
An important reason for the lack of indigenous growth in bioethics has been a lack of capacity toteach bioethics. Human resources in this field were never developed in Pakistan since bioethics wastraditionally never a part of curriculum at any level in the country. Of late, some CPD programs havebeen organized, but they remained confined to the city of Karachi and were based on sporadic personal
initiatives rather than on well thought out institutional strategy. Although these programmes havecertainly helped heighten awareness and interest, they cannot be expected to raise capacity in bioethics
in any meaningful or sustainable way unless provided with institutional support.
Establishment of the Centre of Biomedical Ethics and Culture (CBEC) at the Sindh Institute of Urology andTransplantation (SIUT), Karachi, a public sector institute was the first step in beginning to address thisdeficiency in Pakistan. Inaugurated in October 2004, CBEC has embarked upon a series of educational
initiatives aimed at a variety of individuals, including health professionals, pharmaceutical industry
professionals, social scientists, philosophers, journalists, lawyers, students, and the lay public. The
broad objective of the centre is to raise awareness about bioethics. These programmes have included aquarterly one hour lecture series called the Ethics and Culture Hour, a one-day National Seminar series
on topics of general interest in bioethics, the most recent one being held on Stem cell Research andCloning.
1	 Psychopharmacology (2003) 171:112–119.
2 	 www.pmdc.org.pk/ethics.htm* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

Introduction

27

These varied events have been specially constructed so that the centre has something to offer to a wide
audience. At the same time we also realize that there is a dire need to develop bioethics leadership in
the country that can spearhead education programmes in bioethics, establish bioethics committees
and enhance bioethics capacity in the country in general.

Postgraduate diploma programme in biomedical ethics
As a strategy to address the bioethics manpower shortage, CBEC started the Postgraduate Diploma(PGD) programme in Bioethics in 2006. This was the first such initiative to formally educate bioethics
teachers in the country.

28

Asia-Pacific Perspectives on Bioethics Education

The authors realize that a diploma is a weaker academic programme compared to a masters or a PhD
programme in bioethics. However we initiated bioethics educator capacity building in a phased manner.
In this initial phase, we offer the Postgraduate Diploma Programme to mid-career professionals who havean interest in biomedical ethics and are willing to devote part of their time for a year to develop skills inbiomedical ethics so that upon completion of the diploma, they can start basic bioethics programmes
at their own institutions. In this way the chronic shortage of bioethics capacity can start to be addressed
within a year. The graduates of the PGD programme will have a strong enough grasp of the subject tobe able to teach others, set up ethics committees and develop into bioethics advocates themselves. At
subsequent phases we will introduce a Master’s degree programme and subsequently a PhD programin bioethics. The credits of the diploma program will accrue towards the Master’s degree as well.

Development of the programme
In order to develop the PGD Programme, a core group was formed consisting of subject and educational
experts. Multiple strategies were used to identify the most relevant content for the programme as well as
devise the most suitable format for the programme in terms of its duration and structure. In order to gather
opinions, a questionnaire-based telephonic survey was conducted of key medical educators, deans,principals, and senior faculty members of both undergraduate and postgraduate medical institutions
from across the country (Tallerico, 2005). Informal discussions were also held with the participants ofthe various bioethics programmes organized periodically by the centre and their opinions sought about
the proposed programme. Simultaneously, a review of international programmes in bioethics was also
carried out to study their structure and content.
An educational consultant was included in the core group to help in the curriculum development
process. Simultaneous with curriculum development, an accreditation process was also started with
the Karachi University as the PGD will be offered through the Karachi University.

Course content
Four major themes have been identified on the basis of the selected learning outcomes for the diploma
course. These include the following:
Foundations of Moral Thought
The participants will be introduced to the work of Greek philosophers and given an overview of thecontributions of Anglo-European thinkers whose contributions have contributed to the shaping ofcontemporary bioethics. Participants will also be introduced to the significant contributions made byIslamic thinkers and philosophers to the chain of moral thought.
Clinical Ethics
This will be an important content area since ethical decision-making can be unsettling to many physicians,
who are accustomed to seeking out the single correct answer to many complex ethical questions.
Developing a physician’s ability to reason ethically can contribute substantially to both the patientphysician interaction and health care delivery. A communication skills component has been included

as a subset of this content area since it was essential that physicians should not only acknowledge that
there are different ways to judge what a right answer is but that they should also know how to articulate
their reasons for making decisions.
Research Ethics
Education in research ethics is crucial for researchers engaged in human research. Addressing issuesof human subject research requires knowledge of the rules and norms governing research andskills in ethical problem solving. The primary aim of this content area is to instruct professionals incomprehending ethics of human subject research, and be able to initiate and maintain ethical review
processes at their institutions.
Basics of Curriculum Development

The course format
One of the distinctive features of this course is its modular, on-campus, off-campus part time flexible
format which has been designed to accommodate the schedules of full-time professionals. Full-time
professionals like physicians and nurses find it impossible to take a whole year or two off to pursue adegree programme. This modular programme has been constructed to require only four periods of
one week “contact time” through the whole year when participants will need to be physically present
full-time on campus and attend educational sessions. Each of the modules described above will be thefocus of one contact session. The rest of the year they can remain at work and will be expected to dotheir assigned readings and submit their assignments through email.

Instructional and assessment methods
The curriculum is designed to enable students to experience “deep” learning; and to facilitate thedevelopment of transferable skills. It has been recognized that traditional teaching techniques often
fail to encourage “deep” learning of subject content, which goes beyond short-term rote memorization
to enable the assimilation of new knowledge in a way which allows re-application to unusual situations(Entwhistle, 1988).
The instructional strategy decided upon uses experiential and constructivist learning principles (Duffy
and Jonassen, 1992; Kolb, 1984; Boud, 1985). Participants are provided with a range of on-line andprinted information resources, and have access to tutor support via electronic mail and face-to-facemeetings as necessary.
The success of a programme will be gauged by the quantity and quality of learning that has taken placeand since the emphasis of the programme is on application and critical thinking, the assessment is of
the same competences. Continuous and final assessment will be done and students will be graded on
their understanding of concepts and appropriate application.

Conclusion
There is now enough evidence available to indicate that the Pakistani medical academia generally
lacks the capacity to establish bioethics programmes in the country. That is reflected in the paucity of
ethics committees, both research ethics committees as well as clinical ethics committees and also in theabsence of a relevant indigenous bioethics curriculum for its students, medical and nursing students.

Asia-Pacific Perspectives on Bioethics Education

One of the major aims of this diploma programme is to build the capacity of teachers to develop andrun courses and educational programmes on bioethics in health profession institutions. Many of the
medical personnel are not aware of the principles of curriculum development, hence this module
incorporates a workshop on “curriculum development” which would enable the participants to develop
and organize a curriculum in bioethics in their own educational settings for both undergraduate andpostgraduate medical, nursing and allied health personnel.

29

Attempts at importing bioethics curricula from the West are doomed to failure for obvious reasons:they frequently conflict with prevailing socio-cultural beliefs and religious values. The need of the hour
is to enhance indigenous bioethics capacity by taking practical steps which start to yield results in the
short-to-medium term. The Centre of Biomedical Ethics and Culture hopes that the part-time, one-year
Diploma in Biomedical Ethics will prove to be such a step and it will provide, in the span of a short timea core group of bioethics educators and leaders who will be able to set up basic bioethics education
programs and initiate ethics committees at their institutions as well as act as bioethics advocates. It isalso hoped that this group will provide the country’s first indigenous Masters in Bioethics graduates andthen subsequently PhD candidates and these will form the true academic leaders in the field.

References
Entwhistle, N.J. 1988. Styles of Learning and Teaching: An Integrated Outline of Educational Psychology.
David Fulton, London.
Duffy, T.M. and Jonassen, D.J, eds. 1992. Constructivism and the Technology of Instruction: a Conversation.
Hillsdale, NJ, Lawrence Erlbaum Associates.

Kolb, D. 1984. Experiential Learning. Experience as the Source of Learning andDevelopment. Englewood Cliffs, New Jersey, Prentice-Hall.

30

Asia-Pacific Perspectives on Bioethics Education

Boud, D. et al. 1985. Reflection: Turning Experience into Learning. London: Kogan.
Tallerico M. 2005. Supporting and Sustaining Teachers’ Professional Development: A Principal’s Guide.
Corwin Press.

Knowledge of bioethics among postgraduate trainees
of a medical university in Southern Pakistan: Do weneed to teach Bioethics?*
Inayat U. Memon, M.D.
Liaquat University Hospital,
Pakistan

There is increasing knowledge among the general public about medical ethics and awareness about
patients’ rights vs. health professionals’ responsibilities. Escalating reports of alleged inappropriate
conduct of health-care professionals are being reported in the media, resulting into tense patientphysician relationships and a deteriorating image of health-care providers. Advances in biomedical
technology with the resultant ethical dilemma have compounded the above issue. Although ethicalconduct in medical practice was stressed as early as 1500 BC in Ebers papyrus (Berdon, 2000) the wordbioethics emerged in environmental ethics and biomedical domains in 1970 (Trosko and Pitot, 2003),
and thereafter a growing number of Western medical institutions have included this subject in medical
curricula.
In Pakistan, most of the medical colleges/universities do not offer the subject of bioethics in curricula
intended for undergraduate or postgraduate medical students. The objective of this study is to ascertain
the baseline knowledge of bioethics amongst postgraduate (PG) trainees, so as to help develop acurriculum for PG studies at the Liaquat University of Medical and Health Sciences (LUMHS), Jamshoro,
Pakistan. Existing curricula that were formulated by Western universities and medical colleges wereprepared in a different context, culture and religious background, therefore were considered unsuitable
for Eastern/Asian medical universities. The importance of context and moral variations in ethics and its
teaching was recognized and given due value in similar studies carried out by Hariharan et al (2006) andMattick and Bligh (2006).

Methods
A one-page, 15 item questionnaire was prepared and administered on 74 PGs working in various
departments (obstetrics and gynaecology, internal medicine, paediatric medicine, general surgery,radiology and anaesthesiology) of LUMHS during the month of November 2006. It contained questions
about the frequency of encountering ethical problems in clinical practice, knowledge of existenceof any ethics committee in the institution and its performance, need of informed consent from thepatient during clinical practice and surgical procedures, instituting necessary medical treatment topatients against their wishes, patients’ confidentiality/disclosure, need of informing patients about theerrors/wrong-doings carried out during their management, respect of the patients’ religious beliefs
and recognition of ethical dilemmas. Questions were also asked to assess the knowledge of PGs about
current ethical issues and the history of bioethics/research ethics. At the end of the questionnaire,
opinions were sought about alleged increasing reports of misconduct by physicians. For each question
the respondents were offered three options (“yes”, “no”, “undecided/not known”) or one-sentence
possible answers. The questionnaires were distributed by hand; none of the participants refused torespond, while some of them declined to reply to some of the questions.

* Paper first presented at the Second UNESCO Bangkok Bioethics Roundtable concurrent with the Eighth Asian
Bioethics Conference, March, 2007.

Asia-Pacific Perspectives on Bioethics Education

Background31

Table one : Specialty and Gender-wise break-up of survey participants
Gynaecology &Obstetrics

PaediatricMedicine

GeneralSurgery

Radiology

Internal
Medicine

Anaesthesiology

Total

Male

00

09

07

04

07

03

30

Female

24

07

04

05

00

04

44

Total

24

16

11

09

07

07

74

32

Asia-Pacific Perspectives on Bioethics Education

Results
The following tables reveal there was high frequency of encountering ethical issues in the practiceof PGs. A small minority of postgraduate trainees (eight per cent) knew about the existence of ethics
committees and a majority (53 per cent) of them expressed dissatisfaction on their performance. Almost
all PGs (95 per cent) considered it necessary to take consent from patients (during clinical practice), whilein the case of surgical procedures, informed consent was considered absolutely necessary. Fifty four per
cent of the PGs chose not to administer necessary medical treatment against the patients’ wishes, while
32 per cent wanted to over-ride their wishes in this situation. But when religious beliefs were involved,
43 per cent of them respected patients’ wishes when treatment was against their religious observance.
31% wanted to over-rule patients’ wishes in these situations, while 24 per cent were unable to decide.
The majority (54 per cent) of respondents thought that a patients’ record is confidential and should
not be disclosed to their relatives without their permission. Half (52 per cent) of the PGs were readyto disclose to the patients any errors (if any) committed during their management. Of the remaining
respondents, half (24 per cent) wanted to hide this fact from patients, while the other half (24 per cent)could not decide regarding this problem.
Less than half (43 per cent) of PG trainees were able to recognize ethical dilemmas (withdrawal ofmechanical ventilators). A large majority of them (92 per cent) considered inclusion of the subject ofbioethics in medical curriculum. Only one-third (35 per cent) were aware of current bioethical issues(euthanasia). Regarding the knowledge of evolution of research ethics, a significant majority (67 percent) of them correctly knew about the Helsinki declaration, while only 36 per cent correctly knew about
the Nuremberg code. When questioned about allegedly escalating reports of misconduct by physicians,a clear majority (63 per cent) considered a lack of bioethics training as the responsible cause, while
only 11 per cent fixed the responsibility on the public. Of those polled, 0.7% thought physicians were
responsible for this problem.

Table two: Frequency of encountering ethical problems in practiceFrequency toencounter ethicalproblems

Never

Infrequently

08 (11 %)

02 (3 %)

Once amonth> once a month

17 (23 %)

36 (49 %)
53 (72%)

Decline to reply
11 (14 %)Table three: Questions about knowledge of Bioethics
Yes

No

Can’t decide

Decline to reply

Knowledge of existence of
Ethics Committee.

06 (8 %)

36 (49%)32 (43 %)Performance satisfaction
about Ethics committee.

01 (1 %)

39 (53 %)

30 (41 %)Necessity of informed consent
in clinical practice.

70 (95 %)

01 (1 %)

03 (4 %)

Necessity of informed consent
in surgical procedures.

74 (100 %)00

00

Administration of necessary
treatment against pt’s wishes.

24 (32 %)40 (54 %)

08 (11 %)

02 (3 %)

Disclosure of patient
information to relatives.

24 (32 %)40 (54%)09 (13 %)

01 (1 %)

Disclosing errors to patients.

38 (52 %)

18 (24 %)

18 (24 %)Treatment against religious
beliefs.

23 (31 %)

32 (43 %)

18 (24 %)

01 (1 %)

Recognition of ethicaldilemma.

32 (43 %)

28 (38 %)

13 (18 %)

01 (1 %)

Need for teaching bioethics.

68 (92 %)

02 (3% )04 (5 %)

04 (5 %)

Table four: Questions about history of bioethics and current bioethical issues
Correct reply

Incorrect

Decline to reply

Meaning of euthanasia

26 (35 %)

40 (54 %)

08 (11 %)Correct knowledge of Helsinki Declaration

50 (67 %)

05 (7 %)

19 (26 %)Correct knowledge of Nuremberg Code27 (36 %)

25 (34 %)

22 (30 %)Table five: Who is responsible for alleged increasing reports of medical misconduct?

Responsibility of
medical misconduct

Physicians

PublicLack of bioethics
training

Undecided

Declinereply

05 (7 %)

08 (11 %)

47 (63 %)

13 (18 %)

01 (1 %)

Discussion
Results of the study revealed that there was a significantly high frequency of encountering ethicalproblems by PGs (72 per cent encountering at least once a month) but only 43 per cent could correctly
recognize ethical dilemmas. This fact highlighted the need for training in bioethics. Very few of them(eight per cent) knew about the existence of ethics committees and they were not happy with its
performance. This underscored the need for a visible and functionally active ethics committee in theinstitution. While resolving a situation, like one where administered treatment was in conflict with

Asia-Pacific Perspectives on Bioethics Education

Question.

33

the patients’ religious beliefs, a significant number of PGs (24 per cent) were equivocal, this reflects
an existence of strong religious beliefs and their inability to resolve the issue. Relative unawarenessof current bioethical issues (euthanasia) and older research ethics milestones i.e. the Nuremberg code
(while more familiarization with the relatively recent Helsinki declaration) stress the need for teaching
the subject at both undergraduate and graduate levels.

Conclusions
In the current atmosphere of medical management (with advanced biotechnology, organtransplantation, genetic manipulations), frequent occurrence of ethical problems in medical practice,
relative unawareness of knowledge of current bioethical issues and a lack of skills to resolve ethicalproblems, stresses the need to develop curricula and teach bioethics at both undergraduate andpostgraduate levels. This will help trainees to recognize ethical issues/dilemmas, prepare them to wisely
encounter these issues and will help them to learn skills to resolve them.

References34

Asia-Pacific Perspectives on Bioethics Education

Berdon, V. 2000. Codes of Medical and Human Experimentation Ethics <http://wisdomtools.com/
poynter/codes.html>
Hariharan, S., Jonnalagadda, R.,Wolrond, E. and Moseley, H. 2006. ‘Knowledge, attitudes and practice of
healthcare ethics and law among doctors and nurses in Barbados’, Bio Med Centre Medical Ethics, Vol. 7,
No. 7, <http://www.biomedcentral.com/1472-6939/7/7>

Mattick, K. andat7/12(.
B)-3(t7006. )712(w221K-4(0T)7(1eaching )]95(and )-95(Bases sng )]95(aedical )-75(athics :)-549(W5(aer)Ethics curriculum for postgraduates in obstetrics andgynaecology: How I see it*
Yasmin Wajahat, Ph.D.
Centre of Biomedical Ethics andCulture, Pakistan.

Women with health problems at our hospital constitute an important vulnerable group. Poverty and lackof literacy contributes further to their vulnerability. They are unaware of their rights and empowerment
as enjoyed in developed countries. They are living in a male-dominated society. Women have no say indecision making in the family, including their own health problems. Though it is known that principles
of privacy and confidentiality are amongst the physician’s obligation and contribute to the respect
for the person, this seems to be lacking in the clinical situation. This scenario needs to be changed.
Spreading the knowledge of fundamental ethical principles will help them to establish their clinicalpractice ethically.
Bioethics is an integral form of medical education and it has developed into a mandatory discipline
the world over. However, in the Islamic Republic of Pakistan, bioethics is still in its nascent form.
Members of the medical community played a vital role in the introduction of bioethics in the Islamic
Republic of Pakistan as compared to the role played by philosophers in the West. There is no formal preclinical or clinical teaching done in medical colleges except in one of the private colleges (Jafarey andFarooqui, 2003). This subject is being taught and learnt sporadically by giving a few informal lectures or
conducting discussions. The majority of the postgraduate trainees lack the background knowledge offormal ethics.
A lack of awareness of basic ethical principles and obligations results in coercion, forced decision
making, lack of confidentiality, respect for the person and informed consent that leads to malpractices
and hampers the routine of the hospital. They need to be trained to be able to identify and deal withthe upcoming challenging ethical situations using their own moral judgment2. Realizing the essenceof inclusion of biomedical ethics in medical curricula, the Pakistan Medical and Dental Council (PMDC),
the certifying body, also stipulated (Moazam and Jafarey, 2005) that it should be taught as a mandatory
subject. However, no structured curriculum has been laid so far. In the year 2002, the Code of Ethics
has been revised and published by PMDC recommending the inclusion of bioethics in the medical
curriculum. The College of Physicians and Surgeons, Pakistan provides regular workshops for the
trainees; which includes research methodology, biostatistics and medical writing and an introduction
to computer training. The initiation of mandatory workshops in the discipline of bioethics will definitely
be a favourable step in developing a structured curriculum in bioethics for future postgraduates.
Besides the problem of the presence of a vacuum in medical education and a lack of structured
curriculum in bioethics, there is also a deficiency of trained teachers in the discipline to teach bioethics.
Currently a postgraduate diploma (PGD) course in bioethics is being run by the Centre of Biomedical
Ethics and Culture (CBEC) at the Sindh Institute of Urology and Transplantation (S.I.U.T). The aim of thisis to assist in “capacity building of future faculty and staff in biomedical ethics” (Moazam and Jafarey,2005). I graduated in the class of 2006, the first batch, of PGD graduates from CBEC, SIUT. This paper was
prepared as a part of the pilot project in the Medical Ethics Curriculum, designed to be implemented in
the specialty of Obstetrics and Gynaecology (OB-GYN) at Sobhraj Maternity Hospital where I work.
*

Paper first presented at the Second UNESCO Bangkok Bioethics Roundtable concurrent with the Eighth Asian
Bioethics Conference, March, 2007.

Asia-Pacific Perspectives on Bioethics Education

Rapid advances in medical technology and the complex situations in which medicine is practiced havegiven rise to various ethical issues concerning what is just and right in the behaviour of doctors andpatients, individuals and society (Carmi, 2003). It is the need of the times that our young colleagues
should be aware of the different ethical issues prevailing and being discussed around the globe (e.g.
organ donation, persistent vegetative state, abortion), the context in which they are addressed andmost importantly to relate these issues in terms of our own traditions, upholding our religious, culturaland social roots.

35

Sobhraj Maternity Hospital is located in the heart of Karachi and is a public sector hospital. It comesunder the City District Government Karachi. It receives patients from every nook and corner of the city
as well as from interior Sindh and Balochistan provinces. It is a 110-bed hospital, providing 24-hours
emergency obstetric care. On average 200 patients are seen daily in the outpatient department.
Reporting patients belong to vulnerable groups, i.e. women from the poor socio-economic class with alow literacy rate.
This institute is recognized by the PMDC for providing internships for six months and by the CPSP for
the two year training of DCPS trainees in OB-GYN. The young trainees at the hospital lack the formal
biomedical ethics education from their undergraduate level. I am an associate surgeon in the institution
and in addition to clinical responsibilities, I am involved in the education and teaching programme of
the trainees. The trainees have no background in ethical knowledge. They are fresh interns for a durationof six months, and the DCPS trainees for a period of two years.

36

Asia-Pacific Perspectives on Bioethics Education

Trainees at Sobhraj Hospital are frequently faced with ethical issues relating to informed consent,
confidentiality, privacy, patient-physician relationships, disclosure, honesty and truth-telling. It would
be appropriate to mention cases that have affected patient care.
One case involved a woman from a low socioeconomic family who had five children. She felt fatigued andfound it difficult to carry out the routine chores of the house. In order to look after the family efficiently
she decided to limit the number of children she gave birth to (even though it was too late) and soughttubal ligation. Her husband refused her request to undertake this procedure and threatened her withdivorce. She approached the doctor and asked him not to tell her husband about the procedure. In sucha situation, it often becomes difficult for the doctor to decide what to do ethically.
Another case involved a woman in her first pregnancy. She wanted to have a caesarean section on social
grounds. It is the norm of the culture that her husband and family are involved in the decision making
process and their wishes also have to be respected. What should a doctor do when the husband and theentire family refuses?
Surgery had to be performed on a woman in her late forties suffering from ovarian carcinoma. The
husband and children insisted that she should not be informed of the diagnosis. How can one performsurgery without informed consent? Handling such situations becomes difficult for new and young
doctors.
The designed curriculum is aimed at helping to build capacity in ethical reasoning skills in young doctors,
which will help them to resolve everyday clinical conflicts. These bioethics sessions are conductedduring the training hours of the trainees, who will be utilizing their training period in gaining extra
knowledge and skills in bioethics. The objective of the programme is that at the end of six months, thetrainees should be able to understand the basic ethical concepts (respect for the person, confidentiality,
informed consent), identify vulnerable patients and deal ethically with them, take informed consent i.e.,
involve the patient in decision making prior to the husband/family, apply the principles of privacy andconfidentiality and conduct literature searches and make a presentation on an ethics related topic.
The selected content for the six month programme include the following topics: introduction tobioethics/oaths with an emphasis on Hippocrates’s and Islamic oaths, informed consent, confidentiality/
privacy and discussions of case scenarios based on the ethical issues encountered in clinical practice.
Due to the ever changing issues related to our field, the contents of the curricula can be modified as andwhen needed. This programme was initiated in Sobhraj Maternity Hospital from January, 2007.
The teaching methods are adopted so as to involve students actively, promote critical thinking, ensureacquisition of knowledge and be practical so that they can be implemented during working hours.
Teaching is done during the morning meetings, small group discussions during the service ward rounds
and large group discussions during the teaching rounds.
A morning meeting is held daily to discuss emergency cases of the last twenty four hours with thetrainees. Discussion is followed by teaching sessions or presentations by the trainees. It is utilized
twice a month for biomedical ethics sessions lasting for 45 minutes each. Teaching during the morningmeetings is done through interactive discussions regarding case scenarios. Time is also allotted forstudents’ presentations and guest speaker sessions.
Assessment of knowledge of the bioethical concepts by trainees is done by including a written question
related to bioethics in the monthly OB-GYN tests. This consists of short descriptions of a particularconcept, e.g. definitions, basic principles of bioethics - respect for person/autonomy, beneficence,justice and elements of informed consent.

Conclusion
Biomedical ethics education is a need of our age. The objectives of our programme have been kept few
and simple and topics are closely related to clinical practice so as to make it more interesting for the
trainees. Bedside teaching is preferred as it exposes trainees to different ethical issues relating to patientcare. It is believed that “patients’ are indirectly our teachers”. Furthermore, no extra time is demanded of
the trainees. Since implementation, the bioethics programme has become a teaching programme forboth the trainees and the trainers. It is liable to be modified and improved as and when the need arisesin the future.

I would like to acknowledge Dr. Tashmim Razzaki and Hira Wajahat Malik with whom I discussed the
project and Syed Nabeel Anwer for technical support. Many thanks to my teachers, Dr. Aamir Jafarey and
Dr. Farhat Moazam, for their commendable and unrelenting support, guidance and encouragement.

Bibliography and References
An introduction to bioethics. http://sunsite.wits.ac.za/bio/intro1.htm
Carmi A., editor. 2003. Informed consent. Haifa, Israel: The International Centre for Health, Law andEthics, University of Haifa.
Csongradi, C. 2001. Why teach bioethics? http://www.actionbioscience.org/education/csongradi.html
Emanuel, E.J. 2006. How to redefine a medical education. The Chronicle of Higher Education.
Goldie, J., Schwartz, L. and Morrison, J. 2000. A process evaluation of medical ethics education in the firstyear of a new medical curriculum. Medical Education, Vol. 34, pp. 468-473.
Goldie, J., Schwartz, L., McConnachie, A. and Morrison, J. 2002. The impact of three years’ ethics teaching,in an integrated medical curriculum, on students’ proposed behaviour on meeting ethical dilemmas. Medical
Education, Vol. 36, pp. 489-497.
Jafarey A.M. and Farooqui A. 2003. Ethical dilemmas and the moral reasoning of medical students. Journalof the Pakistan Medical Association, Vol. 53, p. 6.
Moazam F. and Jafarey A.M. 2005. Pakistan and biomedical ethics: report from a Muslim country.
Cambridge Quarterly of Health Care Ethics, Vol. 14, pp. 249-255.
Solberg, M.M. 2005. Thinking out loud about teaching bioethics: a contribution from the edge. Teaching
Theology and Religion, Vol. 8, No. 2, pp. 99-106.
Snyder, L. and Leffler, C. 2005. Position Paper: Ethics Manual. 5th Edition. http://www.acponline.org/
ethics/ethicman5th.htm
Taylor, K.L. and Chudley, A.E. 2001. Meeting the needs of future physicians: a core curriculum initiative
for postgraduate medical education at a Canadian university. Medical Education, Vol. 35, pp. 973-982.

Asia-Pacific Perspectives on Bioethics Education

Acknowledgements

37

Teaching ethics and humanities to medical students in
Sri Lanka: A multi-cultural approach*Anoja Fernando, BA, Mbbs, FRCP,
University of Ruhuna,
Sri Lanka

Introduction

38

Asia-Pacific Perspectives on Bioethics Education

Medical ethics is now included in the curricula of most western medical schools, but it is still not common
in Asian medical schools. Teaching medical ethics is, however, now fairly well established in most Sri
Lankan medical schools. The Faculty of Medicine, at the University of Ruhuna was established twenty
five years ago as the third medical school in Sri Lanka. While professional ethics and legal medicine
were taught in forensic medicine from the very inception of the school, medical ethics was dealt withbriefly through one or two lectures. After a series of workshops for faculty staff on reorienting medical
education in the early 1990s, a formal programme on medical ethics, based predominantly on Westernmodels was introduced in 1995. In the University of Ruhuna, the medical curriculum is a traditional one,and medical ethics is taught throughout the five year course. The outline of the course introduced in
1995 and continued until 1996, is summarised below.

Medical ethics course, Faculty of Medicine, University of Ruhuna,
1995-2006
An introductory lecture is given to students upon entry to the medical school. After five terms of preclinical studies, at entry to the clinical course in the third year, the students have a two week introductory
course of lectures and demonstrations during which the main input of medical ethics teaching occurs.
This consists of a series of seven lectures and one seminar discussing ethical scenarios, given over a periodof one week. The lectures include an introduction, history, ethical codes, doctor – patient relationship,
confidentiality, patient autonomy and informed consent and introduction to research ethics. Student
assessments are not done at this stage.
From the third to the final year, professional and legal ethics are covered by the Department of Forensic
Medicine, and research ethics by the Department of Pharmacology. Summative assessments of students
are done as part of the examinations of both subjects. It was originally planned to cover other specialised
topics such as HIV/AIDS, abortion etc by the relevant departments, however this aspect was not done
consistently. During the final year clinical ethics discussions are held in the wards. A few years ago a
Medical Students’ Oath was introduced at entry to the medical school. An evaluation of the ten-year
programme on medical ethics carried out in 2005 will be presented.

Some innovations introduced in 2005
In order to improve the relevance of the ethics programme to our students, an attempt was maderecently to include Asian medical ethics drawn from the indigenous systems of medicine which haveexisted for many years in India and Sri Lanka. The other innovation was the introduction of Medical
Humanities in October 2005.

Medical humanities
Recognizing the need to balance the scientific practice of modern western medicine with a returnto older humanistic values, medical humanities have been incorporated into the curriculum of many
medical schools in USA and Europe during the past two decades. The primary aim of such courses is topromote the development of humane attitudes in the young undergraduates, who are compelled to*Paper first presented at the Second UNESCO Bangkok Bioethics Roundtable concurrent with the Eighth Asian
Bioethics Conference, March, 2007.

pursue their medical courses in an increasingly complex technical milieu. The most common method
used is to offer optional Special Study Modules (SSM), for which students can register, usually in small
numbers. Sometimes they have been incorporated into existing ethics courses. In general, they have
proved to be very popular with the students.
Teaching medical humanities is rare in Asian medical schools. Constraints include fear of overloading
the curriculum and scarcity of local resources and expertise. In my presentation, I will describe the initialefforts at introducing medical humanities to students of the Faculty of Medicine, University of Ruhuna.
Being the first time that medical humanities were introduced in Sri Lanka, it was rather experimental
in nature. The course was designed to be implemented using available time, resources and skills, andtherefore did not conform to what was accepted as educationally ideal.
While the major proportion of the content was drawn from Western sources, and taught in English,
indigenous sources available in Sri Lanka were also used. This multi-cultural approach resulted in
exposing the students to hitherto unappreciated alien cultures as well as to the realization of theuniversality of human values, emotions and struggles of people all over the world. Evaluation of thecourse revealed that the students had deeply appreciated and enjoyed the course.

• Reflective practice and personal development;• Empathy with patients;• Compassionate understanding of individuals in society
These objectives are very generalised, and also cannot really be evaluated easily. We are also not certain
how or whether aims such as promoting empathy and producing more compassionate doctors can beachieved by studying the humanities. As Robin Downie says, (quoting the example of Nazi officers),“to be versed in the humanities is not the same as being humane.” Downie and others have suggested
more concrete and realistic aims (eg. developing transferable skills such as the ability to communicate,or to analyse arguments etc). Janet McNaughton calls these “the instrumental uses of the humanities inmedical education”, in contrast to objectives such as mine, which she labels “non-instrumental values”,
but nevertheless worth studying for their own sake. Professor Gillon believes that even these so-called“non-instrumental” aims may be instrumental in the simple sense of “being likely to produce better
doctors.”

MethodTen half hour lectures, using PowerPoint slides, were given during normal lecture hours, to fourth year
medical students. The lectures were supplemented by handouts summarizing the main message of thelecture. Topics were drawn from both Western and Asian sources. Attendance was optional but students
were encouraged to attend. No student assessments were done. All lectures were given by a medicallyqualified teacher with a degree in humanities. A preliminary evaluation of the course was done by aquestionnaire after the 6th lecture.
Lecture topics were drawn from the fields of history, art, literature, poetry and archaeology. The firstlecture was on the painting of “The Doctor” by Sir Luke Fildes. This was voted the most popular lecture by
the students. Other examples of lectures were “Ancient hospitals in Sri Lanka”, “The Anatomical drawings
of Leonardo da Vinci”, “History of the Nuremberg Code” and “Alternative systems of medicine”.
In selecting topics, consideration was paid to their relevance to Asian culture and Asian values, students’familiarity with western culture, ethical and cultural relativism, “Asian” medical ethics of Charaka andSusruta, and the influence of Asian religions, such as Buddhism, Hinduism, Islam, Confucianism, andTaoism.

Asia-Pacific Perspectives on Bioethics Education

In teaching medical humanities, I think we go beyond medical (or professional) ethics which deal withwhat doctors should do. In medical humanities, we are more concerned with what doctors should be.
What they are, of course, would naturally guide them in what they do. The objectives of the medical
humanities course started in 2005 were deliberately kept simple. The aim was to promote:39

When selecting topics for the lectures, the general principle I had in mind was to introduce arts subjects
related to medicine “in order to achieve a better understanding of the past, a better analysis of thepresent and a view of the future”. This objective actually appears in a statement made by the US Congress
when it created the National Endowment for the Humanities in 1965.
Since I did not have the luxury of being able to design special study modules or intensive courses on
individual topics, I had to ensure that each brief lecture carried some message, meant for reflection, andfor future improvement in attitudes etc. There was also no opportunity for discussion as in a small groupteaching format. Thus the method used was educationally not ideal, being the didactic lecture type– very unpopular in medical education circles nowadays. My choice of method however, was driven
more by necessity than by choice. Lectures still remain cost-effective in terms of human and material
resources in our part of the world.

40

Asia-Pacific Perspectives on Bioethics Education

A senior Sri Lankan medical academic, S N Arsecularatne, has in the recent past highlighted certain
anomalies in the teaching of medical ethics in Sri Lanka. This may be applicable to other Asian countries
too. He has drawn attention to the fact that we practice medicine of western origin and instruct
our students on medical ethics that is western-oriented, while treating a patient population that is
predominantly Asian in ethos while being culturally heterogeneous. In other words, when teaching ourstudents, we have not paid sufficient attention to the cultural relativism that exists in medical ethics.
However, Japanese bioethicists have for a long time, recognized and written about the cultural relativism
displayed by Japanese people when facing ethical issues in medicine, whether in practice or research.
Recognising that cultural relativism should be acknowledged, I have introduced indigenous, Asian andArabic sources to my teaching of medical ethics, such as eg. The Code of Ethical Conduct for Medical
Students, dating to Caraka, an Ayurveda physician of ancient India. And I have also encouraged thestudents to take into consideration their own as well as their patients’ social, cultural and religious values
when presented with ethical dilemmas.
However, when I was planning the series of lectures on Medical Humanities, I decided that not only
will I try to get the students to understand the social, cultural and historical determinants of medicine
and healthcare in Sri Lanka by studying arts subjects related to medicine in Sri Lanka, but, I will also try
to make them realize the universality of certain basic human values and the commonality of humanemotion and struggles of people from all over the world.
Just as for medical ethics, we have to realize that there is a “cultural relativism” in relation to medical
humanities too. According to one of Sri Lanka’s greatest novelists, Martin Wickremesinghe, westernculture is generally based on reason and science. He maintained that traditional Sri Lankan (Sinhalese)
culture is based on aesthetic intuition. He goes on to say that this contemplative method of developing
the intuitive faculty was originated by Indian thinkers, and that the Buddha perfected the method anddeveloped his intuition to the highest degree.
In the 2500 year old history of Sri Lanka, the predominant cultural ethos was Buddhist, (with Hindu
roots), until the advent of western colonizers and Arab travellers beginning 500 years ago. Now, while
being culturally more heterogeneous, the ethos is still predominantly Asian.
With these observations in mind, topics were selected from both western and indigenous sources. Sri
Lanka is particularly rich in suitable literary sources for teaching medical humanities. For example, theoriginal birth stories of Lord Buddha provide great psychological insights into character, which are
relevant even today. Sri Lanka is also rich in historical and archaeological sources. It is almost uniquein having a written history extending 2,500 years and has been acknowledged as one of the earliest
countries to have constructed hospitals, not only for humans, but also for animals.
Some ancient kings of Sri Lanka have also practiced as physicians and have written medical treatisesthat are in existence today.
One has to keep in mind that 500 years of western colonization was not conducive to the preservationor the development of indigenous culture during the latter half of the second millennium. Sri Lanka
being an ex-British colony, older generations are quite familiar with Western, especially British culture.

Most of the present day medical students however, have not been exposed to good western literature,music or art. A pleasant by-product of the medical humanities course was the introduction of western
literature and art to the students, who were very appreciative of this new avenue of enjoyment.

Results
Ninety nine students, in a batch of 135, attended the 6th lecture and completed the questionnaire.
Student enjoyment of lectures ranged from 80 per cent to 97 per cent and agreement on the relevanceto objectives ranged from (80-88 per cent). The preferred method of teaching was half-hour (69 percent) lectures (71 per cent). Except for four neutral comments, all other comments (38) were positive,
appreciative and indicated that the lectures were effective. 96 per cent wanted continuation of thecourse. Art and medicine was the most favoured topic.

Conclusions

While I have provided quantitative data with respect to feasibility and acceptability, one may question
my conclusion that this course was effective. One cannot say that it was effective in producing more
empathetic or compassionate doctors, at least not yet. However, if one accepts that the three objectivesof the course could be considered in a broad sense as being “likely to produce better doctors”, then it
would be difficult to ignore the students’ own judgments and opinions on how they have benefited
from the course of lectures.

Acknowledgements
My thanks are due to Dr AAG Abeysinghe and Dr KKRP Kodituwakku, for collection and entry of datafrom questionnaires.

Asia-Pacific Perspectives on Bioethics Education

It is difficult to prove that teaching medical humanities in any form to medical students will result in
more humane physicians or better-cared for patients. However, I conclude that short, didactic lectures
are feasible, acceptable and effective as a preliminary method of introducing medical humanities toundergraduates in a developing Asian country with limited resources.

41Ethics in paramedical studies - mapping a new agenda
Sr. Daphne Furtado, MSc. Ph.D,and Karuna Ramesh Kumar, MD.
Ph.D,
St. John’s Medical College,
India.

Introduction

42

Asia-Pacific Perspectives on Bioethics Education

Most bioethicists today understand and accept the need for a clear and systematic analysis of moral value
judgments and decisions. However, they also see all ethical questions as relative to the attitudes andcustoms of the particular society in which they arise. Medical ethics has assumed a kind of principalist
orientation over the years operating on main principles like autonomy, beneficence and justice. A
meta principle, deriving from these, which applies to medical ethics in particular, is professionalism.
This principle provides that physicians/nurses/paramedical personnel have an obligation to observe
certain basic rules, principles and moral precepts governing relationships to patients, colleagues, theprofession as a whole and the community at large.

The setting at St. John’s Medical College
The history of medical ethics at St. John’s Medical College (SJMC), which was the first of the Institutionsof the St. John’s National Academy of Health Sciences (SJNAHS) dates back to the history of the college
itself. As recently as 1998, SJMC was the only Medical College in India teaching medical ethics as a regularpart of its curriculum. Some of the topics are addressed by the Department of Forensic Medicine, whileinterns are required to attend monthly clinical ethics sessions at which cases involving ethical issues arepresented and their resolution discussed by members of the Department of Medical Ethics. The Rajiv
Gandhi University of Health Sciences (RGUHS), to which the college is affiliated, has lately incorporated
medical ethics into its syllabus, largely using the SJMC template and requiring 40 hours over the whole
MBBS course of studies
At the start of the new millennium, when the university introduced B.Sc. courses in medical laboratory
technology, radiology, renal dialysis and perfusion technology, SJNAHS felt the need to expand its
ethical umbrella to include paramedical students as well as students of the College of Nursing, which
also forms part of the academy. This paper traces our initial steps in this venture and the lessons wehave learned about approaches to medical ethics education and educational strategies which could be
successful in the Indian context, as well as constraints and limitations experienced.

Rationale
The paradigm shift from clinical examination based on investigations based treatment increases theimportance of the role and responsibility of the paramedical staff. As the World Medical Association
indicated in one of its documents, some procedures, formerly performed by physicians, are now routinely
done by medical technologists, nurses and paramedics. This results in physicians relying on data fordiagnosis and the technician’s role becoming increasingly important (WMA Ethics Manual, 2005). In
this changing scenario of increasing inter-connectedness between health care providers at different
stages of the system, certain ethical principles need to be included in the courses of students of medical,
nursing and paramedical students, so that the system holds together and remains trustworthy, whilestill providing a personal approach to patients as far as possible.

* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

The Paramedical Ethics Education experiment
At the request of the Coordinator of Paramedical Courses, SJMCH, a sample study was conducted by
the Department of Medical Ethics to assess the level of awareness of ethical issues as they apply toparamedical students. The first year B.Sc. students of the batch of 2004 were selected. The list of graduate
disciplines included under the paramedical courses includes:• Laboratory technology - includes all laboratory services, including the blood bank
• Cardiac perfusion - related to the operation theatre, especially cardiac and thoracic surgeries• Renal dialysis - related to kidney problems; machine-assisted quality of life
• Radiography- related to diagnosis of medical problems; can be extended to radiotherapy of cancers

1. Introduction to ethics
2. Ethical applications in the world of medical technology;-Beginningoflifeissues;-Conflicts in midlife;-End of life issues
3. Concept of life - applied aspects
4. Ethical principles related to diagnosis of medical problems
5. Confidentiality
The programme was semi-structured and conducted over a period of six days.

Methodology
At the start of the programme, the students’ responses to an oral quiz helped to determine how theyenvisaged their role as technologists in the continuum of health care providers and to assess theirknowledge and understanding of human rights, duties and responsibilities, personal value systems,
and the meaning of ethics as it applies to their role in the paramedical profession.
The subject matter was then presented using various methodologies, ranging from the conventional
lecture method to group discussions of case studies and narratives, as well as the use of audiovisuals and films. The sessions were designed to be as interactive as possible and maximum student
participation was encouraged. When a case was presented or a topic introduced for discussion, theimmediate, spontaneous responses were first elicited and then a proper discussion initiated, so thatstudents became aware of their personal biases and processes of socialization. Similarly, films were
followed up by a cine forum so that student reactions could be summed up to highlight a principle orcompare differing viewpoints.
At the end of the programme, each student was required to submit a written assignment on different
general aspects of medical ethics, requiring a module of personal library reference work and discussionof the topic with a group before the final write-up. A questionnaire was also distributed to obtain
individual feedback on the experience.

Results
The group was a heterogeneous group represented by different religion and languages where there
was eight different languages (not dialects) spoken and six different states in India were represented.
Fifteen of the participants were of the Catholic faith, six participants were of various Christian faiths, five
participants were of the Hindu faith and one participant was of the Muslim faith. The methods included
oral quizzes, case studies and group discussions. A qualitative assessment of the responses was done

Asia-Pacific Perspectives on Bioethics Education

The Ethics topics included as part of the study are listed below:

43and the final conclusions were drawn based on the questionnaire given at the end of the programme.
The initial oral quiz
The initial oral quiz showed that the level of ethical awareness was a new concept to nearly all students,
and was considered as important in the medical field. Results indicated that ethics was perceived as amoral code essential to discern between right and wrong. Furthermore, the insight of participants into
medical technology principles of applied ethics was very low, and students were not aware of either
financial or legal pressures.
Hypothetical case studies
In descending order of approach, the group discussions were based on, expected responses, religious
beliefs, personal moral codes, common sense and logical reasoning.
Final assignment

44

Asia-Pacific Perspectives on Bioethics Education(Library module, followed by discussion in groups).
The assignment helped to illustrate certain ethical aspects relevant to the life of students such asplagiarism (a new word and concept to most of the group), transparency in reporting results, integrity
and honesty about personal contributions in a collaborative effort and inner commitment to thesevalues.
Questionnaire and evaluation• The students commented that through this short exposure they were:• awakened to ethical principles;• sensitized to balance between different benefits, risks and duties;• helped to understand their biases through their immediate responses;• made aware of important legal aspects;• helped to better understand their role as pivotal to the health care team;• challenged to being professional (not mere lip service).
They also felt that the course was too short and asked for more input. They highlighted that more films
should be included as they had the greatest impact. Participants noted that they were challenged bylistening to the comments of others and also commented that the library module was very instructive.
Impact of the following aspects on personal change in ethical matters
Finally, it could be seen that the greatest impact on personal change in relation to ethical matters was
education (especially the films), followed by societal factors, to be balanced with education. Religious
factors were considered as only one compartment of life; while tradition was seen as a possible factor(however the present had greater weight). Factors such as conscience were seen as important for oneself
but cannot be imposed on others, while the law was seen as important, but the risk factors very highand often unclear.

Discussion
The fundamental objective of the health care profession is to enhance the overall quality of life, dignity
and well being of individuals needing health care. Furthermore, the health care profession aims tocreate a more equitable, accessible, effective and efficient system of services. Paramedical personnel
who form the backbone of the healthcare system need to be aware of their responsibilities and theirrole in decision making at every stage of life in patient care. They need to realize that the principles

which apply to persons equally apply to individual cells, blood and body fluids and the data derived
from them.
Although the duration of the project was too short to permit assessment of its lasting impact on thepresent batch of paramedical students, it highlighted several areas of importance in the planning of
future programmes in medical ethics education. The first relates directly to a five-point approach to
medical ethics for paramedical students and may be summarized as follows:
1. Dealing with data: It could be said that data is to the paramedic what the patient is to thephysician. Hence data represents the patient and is, therefore, deserving of utmost respect andconfidentiality. Accurate reporting, non-tampering with results, care in maintaining records
and ensuring that they are stored and transmitted securely in the era of computerization andmanaged care. These ethical aspects of dealing with data strengthen the bond of trust withpatients and must be given priority in the context of paramedical ethics.

3. Relationships: Being an important part of the health care team, the paramedic needs tounderstand the ethical value of verbal and written communications, collaboration (working
with others responsibly), accountability (at several levels, including to oneself and the courts oflaw) and loyalty both to society (in the use of technical resources) and to the patient (informed
consent to any procedure prescribed, patient equality and rights, respect for patient autonomy
and confidentiality of computerized data).
4. Conflicts of Care Givers: Sharing in the work of healing, paramedics must be aware of the feesplitting phenomenon, referrals, and the process of conflict resolution, especially in the context
of being whistle blowers and professionals in their own right. Modern thinking tends to put
paramedics on a par with, or even above, physicians. Hence, this could be an additional area ofconflict needing resolution in daily practice.
5. Professionalism: relates not only to what professionals are expected to do, but, more
importantly, to the type of persons they are meant to be. Since this principle cannot be quantified
or tested, except in the unfolding of life’s events, it is difficult to ensure that it is communicatedeffectively in a classroom situation. Educators, therefore, face a great challenge in discussing
professionalism as a principle of ethics. We hope our strategy (outlined below) will succeed atleast to some extent.
With advances in technology, the role of the medical technologist and technician will gain greater
importance, giving it the status of a profession in its own right. We, therefore, recommend thatparamedical students are reminded (similar to the Hippocratic Oath for medical professionals) of thesacred role they play in health care. Such a pledge would certainly help to deepen in paramedical
student’s sincerity in the quest for a professional ethic.
Secondly, the experiment has encouraged us to introduce twenty hours per year of ethics teaching into
laboratory practice/paramedical studies as part of the curriculum over the three years of undergraduate
study and the year’s internship. At every level, but especially in the first year while introducing the basic
concepts of medical ethics, the orientation will be towards personalization of values. The main topics to
be included at each stage of the programme are outlined in Table one.

Asia-Pacific Perspectives on Bioethics Education

2. Competence: is one of the basic principles of medical ethics. Applied to the paramedical field,
it includes regular upgrading of technology, technical skills and life-long learning.

45

Table one: Suggested syllabus outline for paramedical courses at SJMCFirst Year

Second Year

Third Year

(The students learn anatomy,
physiology, biochemistry,pathology, microbiology, which
are common to all disciplines,
and are introduced to theirrespective disciplines):(The students learn more about
their respective disciplines andare aware of medical practice):(The students are involved
only with their respective
disciplines):- AIDS and ethics;- Legal aspects- Cancer and ethics;- Dying and death- Introduction to Ethics- Reproduction and ethics;- Euthanasia- Respect for life – Justice andCare, Informed Consent- Transplant Ethics;- Autonomy, in the context ofIndian culture- Professionalism – Personal
Value-based Ethics;- Genetics and ethics;- Animal experiments.
- Introduction of applicationof basic ethical rules in clinicalsettings;

46

Asia-Pacific Perspectives on Bioethics Education- Confidentiality, Reliability,
Accountability

Finally, we found that students tended to use deeply rooted traditions and religious beliefs in approachingmoral dilemmas. It was felt that conscience had to be the final judge in personal matters, though noone was happy about imposing their values on others, conscientious processes were generally religion,
home, family and education. Personal biases were difficult to overcome, resulting in disagreements
during discussions of case studies, although the majority of the group was Indian. Students admitted,
however, that they profited from interacting with each other and that their discussions continued
beyond the classroom. There was general consensus that values communicated through audio-visuals
remained more deeply embedded and had the greatest potential for changing thought patterns, thus
influencing behavioural change.

Multi-cultural, multi-religious, multi-lingual context
The importance of a multicultural approach to medical ethics both in the classroom and in the clinic is
receiving much attention in the context of the pluralistic societies existing in major cities of the world
today (Turner, 2001, 2003, 2005 and other authors). There is also a search for an approach to bioethics
for the Asian region (de Castro, 1999; Tai et al., 2001) as well as for the sub-continent (Desai, 1988;
Shah, 2003). Ethicists are becoming more aware that a cross-cultural approach is vital and the true
challenge is for each country to develop its own system and methodology (Macer, 2001).
Being a national academy, SJNAHS is home to students from several parts of the country and abroad.
Analysis of the group in the present study indicates that six different Indian states, four religions andeight different languages were represented. This reflects fairly accurately the normal distribution of
student population in all streams of the academy, though we often have a larger number of Muslims,
as well as Jains, Buddhists, Sikhs and Jews. In the 1,200-bed hospital, there is an even greater spread ofreligions, languages and backgrounds among the patients and staff, making the academy truly a miniworld of interlinking cultures.
It is also a sad fact that the health care system in India is plagued by a severe moral malaise. It is forthis world, however, that we prepare our students, hoping that the professional approach we seek toincubate in them will have an impact on the system. The question that needs to be answered afresh withevery fresh group of students is: How can we incubate professionalism within such a system?

The healer in the Indian context
All religious traditions in India attribute a special role to the healer who is expected to be a special
type of person. Thus, in our context, the most appropriate approach to medical ethics education would
be one that focuses on the person of the health care professional, since it would have the appeal of aphilosophical and scriptural base. Rights, principles and duty-based ethics have their value, but theirmoral effectiveness still turns on the disposition and character traits of the persons through whom theycome alive. This is pre-eminently true in times of illness, when the vulnerability and dependence of sickpersons forces them to trust not just in rights, but in the type of person the doctor, nurse or technician
is. As medical ethics educators, our objective must be to make each student the type of person who will
intend and do the right and good thing because they cannot really do otherwise.

• Universities must tackle medical ethics education on a mandatory footing. Subjects must be
incorporated into the curriculum along with “hard” medical subjects, and these additional subjects mustnot be seen as “soft”, additional options. The subjects must exist in a framed module for each year of acourse. Conduct periodic evaluations with consequences which students are forced to take seriously.
• Medical institutions must place medical ethics at the heart of the institution’s goals and actively
encourage it at all levels, in the classroom, at the bedside and in the clinic.
• Recruit teams of interested educators, preferably physicians, whose approach is professional. Preparethem for this important task through workshops and well-planned courses in medical ethics.
• Organise a local medical ethics education cell with the responsibility of preparing educational material,case studies, narratives, audio-visual material so that the task of teaching is not tedious.
• At the Asia-Pacific regional level, initiate collaboration between groups, make possible the developmentof a regional resources centre through which relevant educational material on ethical issues in the formof audio-visual library facilities, films and interactive CDs could be obtained or at least a catalogue of suchmaterial made available.
• Finally, the suggestion to develop medical ethics training centres for medical professionals of the AsiaPacific region is worth re-considering (Miyasaka, 1999).

Conclusion
Although the world of the paramedics may seem to be hidden behind the scenes of the actual medical
encounter between physician and patient, it is vital in the high-tech medical world of today where
diagnosis tends to depend increasingly on the results obtained from technical procedures and tests.
Hence, paramedical students must realize that they are not merely the hands and feet of the physician,but have a vital role to fulfil in the continuum of the health care system today. As medical ethics educators
at SJNAHS, our hope is that our students at every level will be able to influence the present healthcare system in our country by serious application of ethical principles and by aiming at a professional
approach in all they undertake.
Our attempt at SJMC to map a new agenda through an ethics programme relevant to paramedical
students is in keeping with the UNESCO Declaration on Universal Bioethics and Human Rights (UNESCO,2005). Such collaborative efforts, along the lines of the UNESCO regional workshops suggested for the
new millennium, would make bioethics education a rewarding experience for all educational institutions
interested in promoting the subject in the Asia-Pacific region.

Asia-Pacific Perspectives on Bioethics Education

Thus, while we may discuss the principle theories of ethics, our approach must tend more towards thatof a Virtue-Based Ethic (Pellegrino, 2001) and the sub-category of the Ethic of care (Carse, 1991). We
hope that at least some degree of sensitization will take place in the classroom, even though it may
not guarantee persons who are ethical at core. Most attempts at revival of medical ethics in the Indian
setting appeal to just such a radical approach to inner transformation (Pandya, 2000; Shah, 2003).
It is true that classroom courses in ethics can be undone in just a few moments by the attitudes of aphysician at the bedside, so we propose the following strategies.

47

References
Carse, A. 1991. “The Voice of Care”: Implications for Bioethical Education. Journal of Medicine andPhilosophy, Vol. 16, pp. 5-28.
De Castro, L.D. 1999. Is there an Asian bioethics? Bioethics, Vol. 13, no. 3-4, pp. 227-35.
Desai, P. 1988. Medical Ethics in India. Journal of Medicine and Philosophy, Vol. 13, pp. 231-55.
Macer, D. 2001. A Global Ethics Institute in New Zealand and Japan; Perspectives on the Professions,
Ethics in the Professions, Vol. 20, No. 2., pp. 7-9
Marshall, P. and Koenig, B.J. 2004. Accounting for culture in globalized bioethics. Law Med Ethics, Vol.
32, No. 2, pp. 252-66.
Miyasaka, M., Akabayashi, A., Kai, I. and Ohi, G. 1999. Teaching medical ethics: An international surveyof Medical Ethics curricula in Asia. Journal of Medical Ethics, Vol. 25, pp. 514-21.
Pandya, Sunil K., M.D. 2000. History of Medical Ethics in India. Eubios Journal of Asian and International
Bioethics, Vol. 10, pp. 40-44.

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Asia-Pacific Perspectives on Bioethics Education

Pellegrino, E; M.D. Virtue 2001. Theory and Practices in the Health Professions Bioethics Beyond theSound Bite.
Ravindran, G.D., Rev. Fr. T. Kalam, S. and Lewin, P. Pais. 1997. Medical Ethics. The National Medical
Journal of India, Vol. 10, No. 6, pp. 288-9.
Shah, C.S., M.D. Revival of Medical Ethics. International Forum for NeoVedantins; http://www.boloji.
com/writers/drcsshah.htm
Syllabus of RGHUS: Section V - Teaching of Medical Ethics in MBBS Course. 1997. pp. 89-91.
Tai, M. and Chung Seng, Lin. 2001. Developing a culturally relevant bioethics for Asian people. Journal
Medical Ethics, Vol. 27, pp. 51-54.
Turner, L. 2001. Medical ethics in a multicultural society. R Soc Med, Vol. 94, pp. 592-594. Name Journal????
Turner, L. 2003. Bioethics in a multicultural world: medicine and morality in pluralistic settings. HealthCare Analasis, 2003 Jun;, Vol. 11, No. 2, pp. 99-117.
Turner, L. 2005. From the local to the global: bioethics and the concept of culture. Journal of Medicine andPhilosophy, Vol. 30, No. 3, pp. 305-20.
UNESCO. 2005. Towards a Declaration on Universal Norms on Bioethics, Article 23a.
UNESCO Regional workshops to bridge the gap between Science and Technology education for the AsiaPacific (and three other) regions – Expected Outcomes 1-4.
World Medical Association. Medical Ethics Manual. WMA Ethics Unit, 2005. (ISBN 92-990028-1-9.)

To accomplish the life education mission throughbioethics courses in a medical school in Taiwan*
Dena Hsin Sin-Chen, M.N., Ph.D.
China Medical University,
Taiwan, China

Introduction

According to the report of a life education project sponsored by the Taiwanese Ministry of Educationin 2004, the core concept and the content of life education should include five dimensions. These are:interpersonal relationships; career planning; ethics; life and death education; and religious values(Hwang, 2005). Bioethics, a multidisciplinary learning of how to practice a moral life, is an indispensable
part to accomplish the objective of life education.
Recently, the social and ethical issues raised by the use of modern biotechnology are being more widely
discussed across the world. In order to have a sustainable future, we need to promote the bioethicalmaturity of society which means the ability to balance the benefits and risks of applications of biologicalor medical technology (Macer, 2004).
University students of all disciplines, especially health care professionals, need to reconstruct theirvalue system and make ethical decisions on how to use science and technology products in their futurecarrier. In addition, modern science and its applications have empowered ethics to play a greater rolein legal, medical, scientific and policy issues. Therefore, there is a wide-ranging need to find new waysof “knowing” what can effectively create a scientifically informed and ethically involved society and this
could be regarded as a holistic aim of “life education”.
In Taiwan, to fulfil the educational concept of the whole development of an individual, the general
educational (GE) curriculum has been advocated to be designed as a foundation course in universities.
In general, the GE curriculum consists of life science and liberal art courses and was deliberately arranged
to follow four basic principles of educational goals, namely: to cultivate a liberal mind of modern citizen;
to enhance ethical concepts as a human being; to establish native cultures and international outlooks;
and to strengthen the ability of thinking and judgments.
Bioethics education, an international project for informed citizens across culture (Macer, 2004a) featured
in its multidisciplinary learning, and was intended to cultivate skills in identifying existing ideas andbeliefs, making students aware of multiple perspectives, and to search for relevant information andcommunicate the findings to others. It supposedly can enhance the achievement of life education andreach the goal of general education at university levels.

BackgroundI joined the international project on bioethics education for informed citizens across cultures (Macer,
2004b) in 2003, working as a chapter writer and as coordinator for Taiwan. Since the teaching materials
were available only in English initially, they are ideal for high schools in English-speaking countries but
they were more suited for the university level in Taiwan (in particular the full length chapters).
The authors of the textbook included bioethicists from several countries and the contents included avariety of cases (such as organ donation, genetic tests and privacy, germ-line gene therapy, AIDS testing,* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

Similar to other countries, the increasing suicide rate led to initiation of a life education programme.
Suicide has been the ninth most common cause of death in Taiwan since 2000 and is the third mostcommon cause of death in teenagers since 2001. However, life education should have a wider view tohelp the youth to understand life, respect life, enjoy their life and then value their and other’s lives.

49

euthanasia, telling the truth about terminal cancer, animal rights, genetic engineering, geneticallymodified food, artificial assisted reproduction and ecotourism and ethics). Students can select thechapters which they are most interested in and teachers could chose those they felt most comfortable
to teach, or that they judge to be the most useful in students’ everyday living or future career. This
material could be used as a main structure of teaching, however students should not just follow the
texts, but some basic reading and illustrations can also be searched from the web-site resources as
supplementary materials for this course.
This project in Taiwan aimed to evaluate the effectiveness of bioethics education in medical schools andto assess the criteria of success in bioethics teaching. In the earlier year in 2004 there were also trials
conducted with Beryl Lee in freshman English classes in the medical school (Lee, 2004). To follow theconcept of the international project, “bioethical maturity” and increased diversity of ideas are criteriathat can be used to measure the success of bioethics education.1 Accordingly, we may modify andimprove our curriculum and find a consensus in life education policy which also corresponds to ourcultural background.

Implementation50

Asia-Pacific Perspectives on Bioethics Education

Class trials were carried out in five paramedical departments of my medical university – the departmentsof Oral Hygiene, Public Health, Sports Medicine, Occupation Safety and Cosmetics and Pharmacy.
Instead of large class didactic lectures, group activities were the main task in our bioethics course-basedclass. Actually, learning from team work was encouraged as a way to approach bioethical deliberation.
In accordance with method of autonomous learning, students were grouped into several teams, eachteam can select the chapters they felt were the most interesting to work on and present these in the class.
Organ donation, genetically modified food and telling the truth about terminal cancer were the mostpopular topics students chose, followed by, euthanasia, lifestyle and fertility, and ethical limits of animal
use. The supporting reasons for choosing the topic were diverse. For example, students may report thatthey feel familiar with and have confidence in the background knowledge (e.g. organ donation), or theselected issue is a hot topic of a soap opera (e.g. fertility, truth telling about terminal cancer), or it meets
their perception of a real world issue they face (e.g. GM food, fertility), or it relates to their personal
experience (e.g. truth the telling about terminal cancer), or it can connect to their favourite TV program(e.g. animal rights on Discovery channel), and the topic can help them to prepare themselves for their
future role as a health giver (e.g. truth telling about terminal cancer, euthanasia).
After students settled down to focus on a topic, they started to search and read the related materials.
Textbooks from the project were treated as a fundamental resource of reading. Most of the time, thestudents used the Internet and searched for the websites listed in the textbook. Local websites with
Chinese characters have made it easier to gather further background knowledge so that they can havedeep thinking and are able to critically evaluate issues, and potentially take action to face the current
issues.
Then, students prepared for their presentations which included various activities including roleplays, film shows or dramas made by themselves, invited guests’ lectures, group debates and cluster
discussions. In addition each student had to make an outline for the chapter chosen, and present a shorttalk from the team members to the other classmates. To my surprise, students were all very creative inpresenting these topics. The teacher then would summarize and give supplements about the topic after
their presentation. In general, students enjoyed their creative and autonomous way of learning. The
main role of the teacher was to give space and to facilitate learning. In addition, each student should
answer the real-life problems according to her experience from her career specialty. The requirementof team work enabled them to work collaboratively, develop skills for creating deep knowledge and tocontribute to the learning community regarding their ideas about bioethics.

1

See the chapter by Macer in this volume.

Benefits of bioethics learning at the university level
The lack of background knowledge may be a barrier for bioethics learning. Students need to develop
knowledge in bioethics contexts so that they are able to make sense of issues, and have thoughtfulconsideration and debates for ethical issues (Macer, 2004b; Conner, 2008). University level students are
better prepared in the background knowledge and are better at abstract thinking compared to mosthigh school students. It is more likely to expect them to interconnect knowledge contents of personaland social dimensions and to make informed judgments on bioethical issues.

Benefits of team collaboration and autonomous learning
Our trials proved that students at the university level had the required social skills to work collaboratively.
Their progress in bioethical maturity also enabled them to contribute to the learning community
regarding their different ideas and diverse thinking. The policy of carrying out PBL (Problem-Based
Learning) in our medical school has prepared sufficient teacher tutors to guide students in their small
group discussions. This made us feel more confident to expect that students would not lose theirlearning direction as they are strengthening their attitudes of self-directed learning.

Bioethical knowledge needs to be updated frequently to catch up with the speed of rapid improvementin biotechnology. University students are supposed to be skilled to access information from internet
research which makes them alert to every essay related to bioethics assignments. Besides that, a website
page was set up to facilitate student learning. Basically, it included four parts; teaching materials and links
to related information web-sites; a discussion forum; students’ feedback; and messages announcementof class activities. These are ways to improve the course involvement of students and to benefit in theirautonomous learning.

Benefits of course-based classes and English
To attempt to use an English content–based approach was more likely to succeed at the university
level. In our trial, we had quite sufficient rationales to justify that the English materials are beneficial touniversity students, not only in their bioethical maturity but also in their learning motivation in English.
This was based on the assumption of the contents-based approach of second language teaching. It canalso be in accord with English and the government bilingual policy in Taiwan.

Evaluation and conclusion
We adopted the “Bioethics Maturity” model proposed by Darryl Macer (in this volume) as a very importantconcept to evaluate bioethics education. However, to count the numbers of ideas throughout the classand to examine how many different ideas students have are not the only ways to assess students’ ability
to balance the benefits and risks of moral dilemmas. A number of performance assessments weredeveloped to measure the outcome of the course which included essays, oral discourse, exhibitions or
performances, and portfolios. For example, as the course progresses, we encourage students to observe
the social and ethical issues arising in their everyday life and to hand in an essay to analysis one of thoseissues according to their view points. Value clarification and value analysis were the main purpose of thisassignment. Throughout the process, the students would not only review the ethical knowledge theylearned through the course, but also explore their own moral/value systems regarding those particularissues. After review of those essays, we are sure that bioethics education may provide a learning context
to improve students’ sense of identity which may help them to contribute themselves to others and tosociety.
Oral discourse during the class is another important part of class evaluation. Most students do nothesitate to bring out their diverse point of views. For example, during the discussion of altruism in organ
donation, some suggested to view this from the perspective of Buddhism. Accordingly, they claimed that

Asia-Pacific Perspectives on Bioethics Education

Benefit of the Internet as a learning tool51

if people believe the dying soul may suffer from extreme pain when the body was touched or moved
within eight hours of their passing away; to comply to the organ donation means they had readied tosacrifice themselves and had prepared for the suffering. Oral discourse may also stimulate a dialogue
within the class. For instance, in considering animal rights, many Taiwanese customs like soaking wild
animals in wine as nutrient medicinal liquors, or raising super pigs for super pig competitions in folk
festivals were critically re-evaluated by students. As students relate bioethics issues to controversial
customs in society it can make bioethics learning more realistic to everyday life.
The performances of students have shown that “bioethics maturity” can be improved through having abioethics course. The effectiveness of bioethics learning was verified by getting students to have criticalthinking and to internalize many important concepts about life. As noted, students’ opinions about
ethical issues were based on their critical reflection of a personal view. However, global worldviews
should be given emphasis to cultivate open-mindedness and to promote goodwill to accommodate
new views. Generally speaking, we need to keep students thirsty for more updated information, andpromote an attitude of lifelong learning.
Finally, what can bioethics provide to life education? It is, as Socrates said: “We are discussing no small
matter, but how we ought to live.”According to our trials, bioethics, the study of issues related to human
life, can provide a learning context which may address priorities for a life education of the young people
in Taiwan.

52

Asia-Pacific Perspectives on Bioethics Education

References
Conner, L. 2008. “The importance of knowledge development in bioethics”, in this volume.
Hwang, Y.W. 2005. “The Core concept, Systemic structure and Developing strategies of Life education”,
Report of a Project sponsored by Ministry of Education of Taiwan.
Lee, J.H. 2004. “Taiwanese trials of bioethics in freshman English classes”. In Macer, D.R.J., ed., Challenges
for Bioethics from Asia. Christchurch N.Z.: Eubios Ethics Institute. pp. 610-612.
Macer, Darryl R.J. 2004a. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios
Ethics Institute.
Macer, D.R.J. 2004b. “Bioethics education for informed citizens across cultures” School Science Review,Vol. 86, No.315, 83-86.

Biomedical ethics education in post-communist
Eastern Germany*
Heiko Ulrich Zude, Ph.D.
Friedrich-Schiller-University atJena, Germany
I will first introduce the present curriculum and guidelines of the ethical education of students studying
medicine in Germany. This is meant to show the ethical content that future physicians receive inGermany. It has to be noted that the situation in post-communist Eastern Germany differs from that in
the western parts of Germany.

The present biomedical ethics education in Germany
The new Approbation order for physicians from 2002, includes for the first time, biomedical ethics as
an aim of their training in Germany. Since the winter term of 2003/2004 the “intellectual, historical andethical fundamentals of medical behaviour” (BMG, 2002, 2405) are no longer taken for granted but have
explicitly become part of the medical training. This field is called “Theory, History, Ethics in Medicine”(BMG, 2002, 2413) and establishes “Ethics in Medicine” as a subject of medical studies that is relevant for
the examinations.
Despite including ethical education as an aim of medical studies, the approbation order does notcontain detailed information about the content and its implementation. Instead the medical faculties
have to shoulder this responsibility. Therefore the “Academy of Ethics in Medicine” (Göttingen) created asyllabus that the board of the academy recommends the faculties realize (Biller-Andorno, 2003, p. 119).
This syllabus was created, critically following the British core curriculum and consists of three “General
Aims” and eleven “Specific Aims”.
A) The General Aims
The three general aims refer to (1) the communication of a “basic knowledge” concerning ethics, (2)skills and capabilities concerning one’s own moral attitudes and those of others, as well as (3) certain
medical “attitudes and views” such as responsibility, respect, tolerance and beneficence (Biller-Andorno,
2003, p. 119). These fundamental issues are the basis for the following eleven specific aims.
B) The Specific Aims
The specific aims contain the topics:• patient autonomy, information and consent;• physician-patient relationship, relations to the nursing staff and relatives;• medical research;• medicine and reproduction (e.g. abortion, PND, PGD);• medicine and genetics;• paediatrics;* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

To demonstrate, I present two examples relevant for biomedical ethics. In a third step I interpret theexisting differences. This will then lead to the fourth part where I question how far a biomedical ethicaleducation should also make normative regulations beyond a mere hermeneutic-descriptive approach.
Finally, I argue that we have to use normative guidelines in biomedical education in post-communist
Eastern Germany in order to achieve the learning aims of the curriculum.

53• mental illnesses and disabilities;• transplantation medicine;• euthanasia;• public health system;• Responsibility and self-conception of physicians and students.
The autonomous patient leads this list, however it is strange, if not typical for the situation in Germany,
that the authors of this syllabus, who are physicians dealing with ethics, and not ethicists, do not mention
this first topic in their own textbook for physicians (Wiesemann and Biller-Andorno, 2005). Instead they
begin with the second point and the physician-patient relationship. The authors hardly pay attention to
the topic of patient autonomy in their book.
Thus it is expected that the ignoring of this topic also finds its way into the practice of biomedical ethics
education as this is, in Germany, mostly carried out by physicians as the only competent persons inevery subject concerning medical issues.
For many or most German physicians patient autonomy is merely considered a “syndrome”.

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Asia-Pacific Perspectives on Bioethics Education

Differences between East and West Germany; Two examples
The aim of the new Approbation order is to achieve a uniform educational standard for the wholeof Germany. In East Germany, however, biomedical ethics education is confronted with differently
orientated values compared to West Germany. I would like to illustrate this with two examples.
Statistics concerning abortion show significant differences in East and West Germany. The average ofwhole Germany is 175 abortions in a 1,000 births. With reference to this, the number of abortions in six
West German landers lies beneath that average (minimum: Rhineland-Palatinate: 125) and two lander(not taking into consideration Berlin, Bremen and Hamburg) are slightly above (maximum: Hesse lander
at 200). The numbers of the five East German lander are quite different. Here the number of abortions
per 1,000 birth ranges from 210 (in Saxony) to 275 (in Mecklenburg-Western Pomerania). On average, thenumber of abortions in East Germany is significantly higher (average: circa 250) than in West Germany(average: circa 155).
A survey about euthanasia on request from the Allensbacher Institute asked people whether they would
or would not agree with the following statement: “A terminally ill patient in hospital should have theright to choose death and to ask the physician to give him a deadly injection.” In East Germany 80 per
cent agreed (Stimme zu), six per cent disagreed (14 per cent undecided); in West Germany the survey
resulted in 64 per cent agreement and 19 per cent disagreement (17 per cent undecided). It can be seenthat in East Germany the acceptance of active euthanasia is significantly higher than in West Germany(80-64 per cent).

Interpretation of the examples with the help of the socialization
hypothesis
Those two examples could suggest that the right for self-determination of the individual or patientautonomy, which is based on a strong position of the individual, is more prevalent amongst the East
German population and is therefore much more in demand than in West Germany. But this must notnecessarily be the conclusion. We can call this assumption the “autonomy hypothesis”. A competing
hypothesis uses the specific situational change as a basis for interpreting the differences between
East and West (situation hypothesis). In literary discussion up to now none of the two hypotheses has
succeeded over the other.
A totally different assumption considers those two examples with respect to those values, that were
supposed to be implemented during the GDR socialism and considers that 15 years after the system’s
breakdown of 1989/90 still (Pfahl-Traughber, 2000, p. 13) or again (Förster, 2003, p. 13f ) influences thepopulation’s mentality. The world views of materialism and atheism that were propagated in the GDR
could also serve to explain the two examples. With the background of a materialistic-atheistic world
view and philosophy of life it is thinkable that a terminally ill life (euthanasia) or an early unborn life
(abortion) is more easily at disposal. As you know, a theological elevation of human life (“sanctity oflife”) as it is proclaimed in West Germany, e.g. through the Christian churches does not culturally work in
the post communist East Germany and therefore exerts little influence as a lifesaving momentum. This
assumption I call the “materialism-hypothesis”.
The “autonomy hypothesis” is not tenable to explain the attitude of the East German population
concerning euthanasia and abortion because the presupposition for “respect of autonomy” (Beauchamp/
Childress) is a strong sense of individuality and therefore an absolute acceptance of the rights andvalues of each individual person. The absolute acceptance of the individual does not quite belong to theconvictions of a socialist system. The socialist ideology has other preferences (Zeyi, 1989). The collective
has the precedence over the individual; this means “the primacy of the private interest in contrast to the
public welfare has become history […] through the socialist concept of society” (Hoerning, 1999).
Therefore I consider the autonomy-hypothesis is not a safe basis to explain the attitudes of the East
Germans concerning abortion and euthanasia.

In contrast to the autonomy-hypothesis, the materialism-hypothesis is much more in accordance withthe world views that were spread in the GDR socialism. There, “life” is not so much a value on its own
but rather a value for society and therefore functionally determined. To say it more drastically: The valueof life is determined through its efficiency for the society. A strongly paternalistic attitude in socialist
systems is therefore only consequent. Only healthy, strong, productive and strictly educated humans
can serve society. The political system has therefore a vested interest to take care of that.
But this is where my question comes into place, this kind of functional-political determination of thevalue of human beings stands in contrast to the statements of the Universal Declaration on Bioethics andHuman Rights:
There it says in article three:
Human dignity, human rights and fundamental freedoms are to be fully respected;
The interests and welfare of the individual should have priority over the sole interests of science orsociety
Here, the priority of individual interests, individual rights and fundamental freedoms is mentioned, andthat these values should be enforced also against the interests of society.

Conclusion
In order to enforce those values of dignity, rights, and individual freedom meaning the right of patientsfor self determination in the sense of Informed Consent or even Informed Choice, especially in East
Germany it is necessary to introduce an explicit normative orientated education in biomedical ethics.
Hence my thesis;
Without a normative-orientated biomedical ethics in the sense of the Declaration on Bioethics andHuman Rights there is the possibility that patients will not and cannot achieve patient autonomy, that istheir patients’ rights with physicians that were socialized in East Germany and hold on to a paternalistic
rationality as typical for socialistic policies (since the days of Plato). The way from paternalism to informed
Choice in East Germany still will be a “long and windy road”.

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The normative points of view in ethics in medicine

55

Acknowledgment
I acknowledge Ms. Kerstin May for her excellent support in translating this text from German.

Bibliography
Beauchamp, T. and Childress, J. 2001. Principles of Biomedical Ethics. New York, Oxford. 5th Edition.
Biller-Andorno, N. et al. 2003. Lehrziele „Medizinethik im Medizinstudium“. Ethik Medicine, Vol. 15, pp. 117121.
Bundesministerium für Gesundheit (BMG). 2002. Approbationsordnung für, Ärzte. Bundesgesetzblattes
BGBl. I Vol. 44, pp. 2405-2435.
Förster, P. 2003. Junge Ostdeutsche heute: doppelt enttäuscht. Ergebnisse einer Längsschnittstudie zum
Mentalitätswandel zwischen 1987 und 2002. Aus Politik und Zeitgeschichte, Vol. 15, pp. 6-17.
Ministry of Health, People‘s Republic of China (MHCh). 1989. Regulations on Criteria for Medical Ethics
and its Implementation. In: China Hospital Administration 9, pp. 5.
Pfahl-Traughber, A. 2000. Die Entwicklung des Rechtsextremismus in Ost-und Westdeutschland. In: Aus
Politik und Zeitgeschichte 39.

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Wiesemann, C/Biller-Andorno, N. 2005. Medizinethik. Stuttgart – New York (Thieme).
Zeyi, Cao. 1989. Medical Ethics in China. Bochum: Forschungskolloquium zur Medizinischen Ethik, März.

Teaching moral values for high school students in the
Indian context*
P. Senthil Kumaran, Michael A.
Jothi Rajan, T. Mathavan
Madurai Kamaraj University,
Arockiam Thaddeus
Jayaraj Annapackiam College for
Women, India

Introduction

Respecting other’s freedom
People who are living in the world are equal and all the people of the world are granted equal rights.
Everyone has the freedom and right to live, as they desire. If a person tries to dominate others it will be
an undesirable action, which must be strongly opposed. It is important for people to realize that others
have the same freedoms which are possessed by all of humankind. When a person respects another’s
freedom, so too will his or her freedom be respected. If individuals fight to uphold the freedom of others,
they are considered a tolerant citizen.
The teacher kindles the hearts of the students to pay respect to the freedom of others. The teacher can
improve the attitude of the students to respect the freedom of others, narrating the true life-incidentsof eminent leaders who fought for the rights and freedom of others. For example, the contributionof Rajaram Mohan Roy, Mahatma Gandhi, Thanthai Periyar (Mr. E.V.R.) who fought to eradicate
untouchability from Indian society may be cited. Several famous Indian historical movements carriedon the fight for others, and may be given as examples of freedom like the Vaikkam movement andthe temple entry movement of dalits (untouchable caste), and the teacher must facilitate the student’s
understanding of the importance of respecting other people’s freedom.

Respecting the feelings of others
The sense of feeling and sharing the feelings with others is a good way to distinguish human beings
from other living beings. There are many human feelings such as, the sense of hunger, sleep, love, desire,anger and joy. One must know the importance and the value given to one’s feelings as well as the feelingsof others. The sense of kindness shown to humankind, understanding and responding to others’ feelings
in a good way are the noblest of human feelings. Understanding and responding to others’ feelings ina poor way causes confusion in family, cuts the friendship and creates ill feeling in the society. The
human mind irrespective of its youth and elderliness has the tendency of having pleasing moments. In
isolation the human mind is either happy or worried by recalling so-called pleasing moments.
If any other person tries to know the confidentiality of the other person, a quarrel will take place between
the two. Hence, everyone has the right to confidentiality.
When the family members fail to respond to other’s feelings, jealousy increases and destroys the love
* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

Among all the creatures in the world, humans are the most powerful species. Humans are distinguishedfrom other creatures with special features like the sixth sense and a generally higher Intelligent Quotient(IQ). When the culture of humans developed, moral values also formed, such as to persuade people tolive in peace. In this article, moral values which must be embedded in the minds of the high school
students and the reasons for acquiring such values are explained in the Indian context.

57

among the members which breaks down the family unit. Because of the above stated reason, theparents are either made to live in an “aged home” or left as “orphans.” The ratio of parents either placedin an “aged home” is rapidly increasing in India. This is the country where “Rama” renounced his “crownof empire” and lived in the forest facing numerous difficulties for 14 years for a single word of his father
that indicates the demolition of social values. If one starts to give respect to others’ feelings, then the
person will respect the noblest human feelings called love, adjustment and sacrifice. So, it is the great
duty of the teacher and parents to create in the students the sense of “respecting other’s feelings.”
To motivate the students to make adjustments with one another, to sit as a group and share with themfood and feelings helps to create an atmosphere of involvement. By doing this, the teacher can inculcate
the sense of respecting others’ feelings in the student’s mind.

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Socio-cultural restrictions
Every society has its own traditions and culture. The tradition and culture of the society are kept intact
by means of moral values and socio-cultural restrictions. A society that follows the social rules andrestrictions in the best manner will become an ideal society among societies in the world. The moral
values and rules followed by the society have been formed to help the people to live in peace with thesocial boundaries. These values and rules have primarily been formed for the welfare of the society andframe the individual’s desires and freedom, because a person who has several desires will not be offeredunrestricted freedom to have his desires fulfilled. If one was to fulfil all of his or her desires, this would
have an impact of disturbing social cohesion. There are no boundaries for human desires. A fresh desire
will arise at the time when the older one gets fulfilled. The endless desires cause many difficulties. So,
the desires of the individual must be strictly shaped.
The desires of the individual, which affect the social values, must be sacrificed for the well being of
the society. If an individual realizes that a desire is not beneficial to the society, immediately the desire
must be sacrificed. Every individual is a brick of the great social building, the moral values where sociocultural restrictions are the cement which binds the individual bricks. If a brick (an individual) tries tocome out of the cement binding (Moral values and socio cultural restrictions) the whole building will
be destroyed.
So, the teacher should train the students to realize that endless and unfair desires would demolish thesocio-cultural edifice. The teacher can cite examples from the “Purina’s and Folk tales” for such endlessand unfair desires, which cause destruction. They can explain the life incidents of great leaders like
Mahatma Gandhi, Kama ajar who even sacrificed their great and fair desires for the well being of thesociety. The teacher can inspire the minds of the students to follow such great leaders.

Patriotism and national awarenessIn many of our contemporary societies, violence, terrorism, rationalism, communalism and corruption
are major problems which have made inroads into the foundations of the Indian nation. The students
must be aware of these problems. The teacher should discuss with the students, the reasons, solutions
and the methods of tackling these problems. The teacher can mould the students into patriots by tellingthe features of the Mother land, its honourable traditions, and the martyrs who sacrificed their lives
for the nation. Then only an energetic younger generation, which has both the sense of solving the
problems, faced by the nations and burning with patriotism, can be created.

Reservation system in India
The reservation systems followed in education and employment by the Indian government were formed
to promote and equalize the economic inequities and improve the life background of all the people ofindependent India. This system of reservation is formed on the basis of the economic background of thepeople in India at the period of independence. However, the people do not understand properly theadvantages of the reservation system. They think that it was formed on the basis of the caste system.
After 60 years of independence, the reservation system is not able to achieve its ultimate goal. The

people commit malpractices to get the governments’ concessions. The competition of wealthy persons
with the poor for government concessions makes this system inefficient. If the government concessions
rapidly increase, it will decrease the self-confidence of people and they will begin to long for free
concessions. The selfish politicians take this attitude of the people for increasing their wealth, as they
are given a lot of free concessions. The people also support the politicians who are able to own a lot offree concessions. This causes plenty of expenses and affects the nation’s economical status as well as its
development.
The teacher can explain to the student the basis and ultimate goal of the reservation system and must
discuss with the students the reconstruction of the old reservation system on the basis of today’s crisis.
The teacher should motivate the students who are eligible to apply for government free concessions.
By such steps, the next generation could be prompted to have loyalty and the mentality to help thegovernment to achieve its goal.

Students are deluded to believe that their parents and teachers always curtail their desires. But, thereasons for curtailing their desires are not explained to the students, nor are they interested to know
them. If all the desires of the students are fulfilled, it will make the students stiff-necked persons. The
great desire is a dangerous one; hence a Tamil proverb says that “Great desire, great loss.” If a student has
all their desires from childhood days fulfilled, it will make them feel egoistic and supreme (I‘m the best,
all things must happen as I desire). If a student has such mentality and possesses great desire, ego andis stiff-necked, it will affect the mentality and personality development of the students and also social
welfare.
The teacher must explain such conditions to the students and prevent the students from facing theabove said problems. The parents and the teachers curtail some desires of the students, and the teacher
must also explain the socio-economical reasons for curtailing some desires of the students by theparents.

Prejudices among the students
The world is full of competition and is of different kinds. But the competition rising among the students
is entirely different. The way of handling the problems by the students in school days will determine themethods of handling problems by the students in the future. So, the students come forward to solve
the problems that arise among them with an open heart and a sacrificing attitude. This habit will help
students to become great leaders in the future.
The class student leader misuses authority to punish classmates who have a difference of opinion, withthe help of the teacher. It implies the attitude of misusing the powers by the students. If a student
has tried to stop a good opportunity which comes to students who are more talented in education,
sports and other extra and co-curricular activities, jealously was implied among the students. To attract
girls, boys often indulge in teasing other boys and get involved in meaningless arguments. Often malestudents will try to behave as a “hero” among the boys which causes animosity among the students.
The teacher must explain to the students that if they are involved in such activities, it will affect their best
student days that develop their education and other talents. By encouraging the students to acquire
noble principles such as respect for others’ talents, solving their problems by sacrifice, friendship, loyalty,
love, hard work, attitude of competence and self-confidence, the teacher can teach tolerance among
the students and also help them to develop the personality of the students.

Impact of mass media technology
The development of mass media technology with the help of science and technology is gaining rapid
momentum. Hence, the 21st century is called “The century of mass media technology.” The cinema andinternet are the two branches of mass media technology which impact a lot of the student body.

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The reasons for curtailing the desires

59

CinemaOf the impact of cinema on society, the bad films have an evil influence. Contemporary films arecharacterized by violence and often highly sexualized scenes and are most often released. A sense ofevil is forced upon the people’s mind through these types of films. Because of this, civil society, and inparticular students favour these types of films indirectly. It spoils the social culture. A lot of harmful
impact is caused to the students by such films. The primary one is, hero-worship given to the film stars
by the students. This attitude forces the students to change their style of dressing, walking, speaking
and they imitate the so-called film stars. The students miss their classes and go to watch films en-mass.
The students also get involved in following worthless activities. These activities spoil the precious timeand opportunities of the students.
Internet

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The public use the Internet for many good purposes. Any information from any part of the world canbe gathered easily through this medium. Some people also use the Internet as a source of income,sometimes unfairly. To earn money, a lot of bad and unfair information is telecast through the Internet.
The availability of illegal information such as pornography, diverts students away from their studies.
The students who are involved in these activities with the guidance of bad friendship divert theirconcentration and they not only fail in their studies but also lose their good moral habits. Hence, thestudents fall prey to evil habits like indulging in undisciplined activities such as stealing. Because of
these reasons, the future of the students has become bleak.
The teacher can explain to the students how to avoid these mass media technologies like cinema and theInternet, which can cause a bad influence. The teacher must train the students to use these technologies
only for their education and future life in a good manner. It is the duty of the teacher to explain thesethings to the students. He must tell them, “The cine-heroes are not real heroes. In day-to-day life they
are also common people like other people, and in any way, the students are not less important thanthem.” By such explanations, the teacher can develop the self-confidence of the students. The teacher
must also to make the students realize that their attitude spoils the hope of their parents.

Conclusion
It can be concluded that moral values must be taught to the students who are studying in high schools,
because this period of age is a suitable one to imbibe moral values in the minds of the students. The
teacher has a vital role in teaching moral values to the students and a responsibility to shape the students’behaviour and in doing so, their futures. It has become clear that students must be aware of the evils
of mass media like cinema and the Internet. Furthermore, it is important for students to maintain theirself-confidence, by concentrating on activities that help to shape their future life and social welfare.

References
Atmanad, M. 1973. Grants in Aid of Educational in India, Madras.
Chidambaram Pillai, P. 1993.Right of Temple Entry, Nagercoil.
Desai, I.P. 1985. Caste, Caste Conflicts and Reservation, Delhi.
Hermen, J. 1999. A Classified Collection of Tamil Proverbs, Asian Educational Services, New Delhi.
Muthukrishan, V. 1991. Viduthalaivelvi, Madurai.
Ravindran, T.K. 1975. Vaikom Satyagraha and Gandhi, Trichur.

Environmental education and eco-ethics – current
trends in education*
M. Selvanayagam and Francis P.
XavierLoyola Institute of Frontier Energy,
India
In a recent judgement (2002), a bench of judges, Justice Shri. N. Santosh Hegde and Justice Shri. B. P.
Singh asked the Indian National Council of Educational Research and Training (NCERT), the All India
Council for Technical Education (AICTE) and all the state governments in India to explain the serious
lapse on their part on not implementing the court order to make environmental education compulsory
in all the higher education institutions.

In the vision statement they said:• The importance of environmental studies cannot be disputed;• The need for sustainable development is key to the future of humankind;• degradation of our environment is linked to continuing problems of:• 		
pollution;• 		loss of forests;• 		solid waste disposal;• 		issues related to economic productivity and national, as well as ecological security;• no citizen of the earth can afford to be ignorant of environmental issues;• managing environmental hazards and preventing possible disasters has become an urgent need;• need for public awareness;
The module consists of eight units as below:
I- multidisciplinary nature of Environmental studies
II-Natural resources
III- Ecosystems
IV-Biodiversity and its conservation
V-Environmental pollution
VI-Social issues and the environmentVII- Human population and environment
VIII- Field work
We need to educate points such as: Why we should not over exploit our Natural resources? Why should
we conserve and protect our ecosystems?; The importance of biodiversity; The impact of environmental
pollution; The importance of field work - to understand what is going on around our habitat. They
explained the importance of “values” education. “Values” education is not just the same as ethics, or
environmental ethics?
* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

The court had directed the University Grants Commission (UGC) to prescribe a course on environmental
science for undergraduate and postgraduate levels of higher education. An expert committee wasappointed by the chairman of UGC under the chairmanship of Prof. Erach Bharucha, and Bharati
Vidyapeeth, Director, Institute of Environmental Education and Research, Pune.

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How we can inculcate these values among the youth
Value education is to produce a citizen with good character and personality. Good citizens are paving
the way for the development of the country. Value education, environmental education with ethicalvalues – or environmental ethics makes an individual conscious of the importance of environment,
making them a more responsible citizen to protect and conserve nature for future posterity.
Many questions are important to develop respect for all forms of life:• Where do the things that I consume come from? Nature and interlinking with flora and fauna;• What do I know about the place where I live? Our role in society and nature;• How am I connected to the Earth and other living things? Food chain and food web;• What is my purpose and responsibility as human being? Protection and conservation.

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Can we advocate the following?
• Refuse: Sewage and industrial waste water should be adequately treated and raw materials recoveredfrom it whenever possible before it is released into rivers and water ways.
• Reduce: Reduction is the best option if there is a reduction of waste generation and the pressure on ouralready stretched natural resources is reduced.
• Reuse: The next best option as a product is reused in its current form without any energy expenditure toconvert it in to a new product.
• Recycle: The last option, although it converts waste into a resource, it uses energy to transform that
resource into a new usable product.
In the campus environment there are some practical suggestions:• Can we have certain healthy practices in our campuses which are simple but useful? Such as rain water
harvesting.
• Use of alternatives for plastic bags: The fancy packaging of consumer products in two or three layers is
not necessary. Furthermore, we can use our own reusable cloth or jute bags instead of plastic bags.
• Can we promote and support eco clubs? Residual waste can be converted into reusable resource. For
example, using kitchen waste to make compost that can be used as an organic fertilizer or sewage in abiogas plant to make fuel.
• Can we involve students in educating our neighbourhood about the environment and health? Cloth rags
from the textile industry are brought and used by paper and other industries.
The judgment leaves us some important educational challenges, namely:• Do we have enough people power to teach this compulsory subject?
• How to develop capacity building: Make others follow environmental friendly practices.
• What is your plan of action? Try to get motivated teachers, even those who have not studied the subject
during their course of education and give them more field oriented knowledge.
• Organize more exposure programmes: Environmental sensitivity can grow through a major publicawareness campaign. Like electronic media, press, school and college education, adult education andeducation for policy makers. The types of field sites include: Ecosystems - grassland, different aquatic
ecosystems, hills, forests; Polluted industrial sites.
• Educate them to appreciate nature and natures’ beauty

Asia-Pacific Perspectives on Bioethics Education

Environmental ethics helps us to respect, appreciate, protect and regenerate the environment. It
creates a love for nature and it forces us to use nature’s gift more prudently, avoiding and reducing thewaste and destruction. We need a “Green” lifestyle, to change our directions. “Nature has everything foreverybody’s need, but not enough for one man’s greed.”63Value Education: Treasure of a Nation*
Michael A. Jothi Rajan and
T. Mathavan
Madurai Kamaraj University
Arockiam Thaddeus
Jayaraj Annapackiam College for
Women
V. Fragrance Latha
Thiruvadavur Government Higher
Secondary School
J. Agnes Jecintha
Sirumalar Girls’ Higher Secondary
School at Nagamalai, India

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Introduction
Nelson Mandela said: “The question of poverty and lack of education, those two combined is thegreatest problem facing the world right now”. What he meant is we need the education embedded with
noble human values to alleviate poverty. The problems faced by educationists are innumerable. One
such problem is the introduction of value education. In many educational institutions, value education
is taught as a separate optional or compulsory subject. Values of individuals and society change fromtime to time. But values which educate on the right way of living never change. Value education text
materials are prepared with great care incorporating wonderful examples. Yet students take this coursevery lightly.
Values should not be taught in a formal way. Values are caught rather than taught. A better method to
introduce values will be to teach it along with the main subject. For example, while teaching Newton’s
third law of motion in physics, after giving proper explanations, the teacher can say “good actions
in life bring good rewards and bad actions bring punishments”. Thus values could be introduced ineach and every subject whenever and wherever possible. An attempt is made in this paper to study
the effectiveness of the direct and indirect methods of instructional procedure to teach values at any
level of education. A carefully framed value education reading material will mould the pupils’ as better
citizens of their country.
As we march in the twenty-first century enthused by the extraordinary human achievements in the fields
of science and technology, the picture on the other side concerning human society appears gloomy. If
a well known writer said that today’s age can be described as an “Atomic Giant” and an “Ethical Infant”,
another observed that the problem of modern world is the mismatch between increasing technologicalpower and decreasing social wisdom.
Many people do not have a clear idea about values, and the significance of values in social life. “Values”
are abstract ideals. In most of the subjects taught, we are forced to say that the ideal parameter is neverattainable. For instance, in physics we say “An ideal heat engine never exists”. If such is the plight of an
exact science, we can imagine the practicality of an abstract quality of life. Yet “value” is the most abstract
ideal which can be practiced cent-percent in a human’s life. It is the strategies which are planned by theteacher and executed in and out of the classroom that make an everlasting impact on young minds.

Methods“Value Education” can be imparted by direct or indirect methods. Nearly 20 schools and 10 colleges in
the Madurai region of Tamil Nadu State offer an optional paper on “Value Education”. One Hour is allotted
per week for teaching “Values”. A good syllabus is framed which contains the methods, procedures,* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

contents and practical aspects of achieving human values. Teachers who volunteer themselves are givena chance to handle these classes which is in addition to the prescribed working hours. Seminars arearranged where speakers from various service organizations are invited to interact with the students.
At the end of the academic year an exam is conducted in schools and the results of this exam plays animportant role in the promotion of pupils from one class to the higher class. In colleges at the end of thefirst semester a student has to write and pass a compulsory examination. This is the method followed inschools and colleges in teaching “Value Education” to students. It is a better method in itself as it gives
the students a change from the monotony of academic subjects.

Indirect methods
Since values are abstract ideals they can be taught to students by indirect methods. The methods thatcan be suggested are:i) Value oriented Educational Procedures in the classroom and teachingii) Extension Activitiesiii) Field–trips and Excursions

In the classroom teachers focus on:• Motivating the learner towards desirable objectives.
• Facilitating his attainment of these objectives, through providing suitable learning experiences.
Teaching is useful only to the extent it facilitates learning. An incidental and casual approach to teachingmust be replaced by a planned and conscious approach. It is well said that a country’s future is shapedin the classroom. This is true as far as teaching of any subjects is concerned. The subjects taught in theclassroom are unique (e.g. physics, chemistry, etc.), interdisciplinary (e.g. bio-physics, medical physics,etc.) and trans-disciplinary (e.g. bio-ethics, bio-logic etc.). Teachers should update their knowledge
everyday by exposing themselves to the mass media where more information is available.
In this section, an attempt has been made to link the law or principle taught in the unique subject to thevalues of life. Every subject (discipline) has its own inherent values. It is the role of the teacher to explain
the law and relate it to life situations which will create an everlasting impact on the learner.
Though many teachers want to adopt this method in their classroom teaching, the heaviness of thesyllabus gives limited time for discussing “values” which are found in the subjects taught. The method isvery simple and more effective.
When a teacher introduces Newton’s third law of motion, he explains the law, derives the necessary
equations and quotes some examples. Though the teaching of law is over, the “value” behind it canbe extended by saying “a good action in life fetches us good rewards and bad actions fetches us evil
rewards”. This is an indirect method of introducing “values” in the classroom. When the teacher has awill there is a way for him. This is an easy example to introduce the value of “being good”. In each andevery aspect of the subject taught, the teacher can link them to the “values” of life. This is not limited tophysics only but can be applied in any subject at any level whenever and wherever possible. This requires
the willingness of the teacher to submit him entirely to the teaching profession and by updating his
knowledge through books, journals, diaries and magazines.
(ii) Extension activities
Besides NCC (National Cadet Corps), or NSS (National Service Scheme), many institutions in Madurai
region offer extension programmes to students where it is compulsory to pass the course. In the present
case a survey was made while the students of our college were undergoing the extension programme

Asia-Pacific Perspectives on Bioethics Educationi) Value oriented educational procedures in classroom teaching65

in a nearby village. Nearly 120 students of the second year undergraduate courses admitted that theycame to know the hardships of physical labour. The learners came to know the value of physical work
done by farmers and child labourers. More number of surveys of this type can be conducted and theoutcome of the extension programme can be analyzed in terms of achievement of “values” of life.
(iii) Field-trips and excursions
Field-trips and excursions can play important roles in cultivating positive human values in young minds.
The students of the third year physics undergraduate course were taken on a tour and were asked tovisit the homes of the mentally challenged and physically challenged in different regions of Tamil Nadu.
After a week’s tour to other academic and cultural places of interest, a questionnaire was given to each
student to pick out the best place they have visited. Almost 78 per cent of the students wrote: “Thevisit to the home for mentally retarded” while 14 per cent of the students wrote: “The visit to the homeof the physically handicapped”: whereas only eight per cent of the students wrote: “The visit to theplanetarium”.
This study reveals that the students have indirectly been oriented towards noble values such as caring,helping and offering compassion to others. They had weighed the “gift” of their life by comparing it withthe less fortunate people whom they came across during their tour programme.

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Asia-Pacific Perspectives on Bioethics Education

Direct method versus indirect method – an analysis
A survey was made in 10 Colleges in Madurai Region where “value education” is offered in the firstsemester of the degree course at the undergraduate level. The survey was made to explore theeffectiveness and usefulness of “Value Education” being taught as a separate subject, one hour per
week. The study was restricted to the final year undergraduate students as they have rich experiences in“Value Education” compared to first and second year students who undergo “Ethics Education”, Religious
Education”, “Social Dynamics” and “Extension Activity” in the first four semesters of the undergraduate
degree.
Due to a shortage of time and other ethical reasons which often hinders the progress of any research
activity (particularly in the field of “education”) the questionnaire could not be served to all the thirdyear students of all the ten colleges. It was not a questionnaire but a survey of opinion. In two colleges
it was circulated with the prior permission of the management and in other colleges through the good
offices of friends and postgraduate students. The survey of opinion reads as follows:
Dear Friend,
Greetings, you have studied “value education” in the course of your studies and you havegreatly benefited from it. You have also undergone training in community service by the“Extension Activity”. You are doubly benefited by the inclusion of this type of programme.
Moreover teachers also relate “values” of life while they are teaching your major or ancillary
subjects. Two statements are given below. Write your order of preference. Be free and frank.
Your answer will be kept confidential. Go ahead.
- I am satisfied with the theory classes on “value education”- Though I am satisfied with the theory classes partly, it will bewholesome when I am taught them in the real subject situation and ina practical life situation
The population was 423. This included boys and girls from science and arts disciplines. The survey of
opinion was analyzed and the preference of the students were studied and entered in Table one as raw
data.

Table one: Results of question on value education (N=423)
Item

1st Preference

2nd PreferenceSame Preference

(a)

49

350

24

(b)

350

49

24

Total

399

399

48

Analysis of the data
Analysis of the raw data collected indicates that students prefer (b) to (a). Students have a liking for“value education” being taught as theory. They feel that it will be more helpful if “values” are taught
along with major and ancillary subjects and also through extension activities.
Advantages of the indirect methods
1. Students appreciate the usefulness of the major subject in relation to daily life.
2. It makes the classroom teaching more lively.
4. The teacher becomes a source of inspiration.
5. The monotony of the daily, orthodox, traditional method of instruction is broken.
6. There are more chances that the abstract values studied put into practice in the classroom
itself, at home then and in the society at large.
The learner is motivated in the right direction to face the challenges of life when embarking on a careerin the future and throughout the span of adult life.
ReportThough “Value Education” and “Value Oriented Education Procedures” help learners to mend their walksof life in the right path it is “Value Oriented Educational Procedures” plays a major role in incubating thepositive values of life by touching their heart rather than the brain.

Impact of media on values
The media is one other medium which transports “values” into young minds. The present day media
focuses at least 70 per cent on “negative values”. Since the learners are in the period of adolescencethe media plays an important role in shaping young minds. It is the duty of the teachers and parents
to censor some of the unwanted news and programmes in the media. A counselling centre can be
attached to every school and college and dedicated teachers’ services can be made use of in giving
counselling to students individually or as a group about the “negative values” projected by the media.

Conflict between social and personal values
Conflict is a word used to identify those situations wherein a person is motivated to behave in two
incompatible ways. There is a difficulty in choosing between two alternatives. Lewin describes conflictas an interaction between an individual and the environment.
Social values are more important than personal values. A noble person sacrifices his “personal values”
if the society is disturbed by his actions. Adjustment mechanisms are almost used by all people. The
learner is given orientation towards the “social values” than “personal values”. Learners should be taught
in such a way that the personal values fall in line with the social values and in the most difficult situation
to strike a balance between the two.

Asia-Pacific Perspectives on Bioethics Education

3. Learner gets firsthand experience in the subjects and mends his ways accordingly.

67

Value crises and setting priorities
The present age is one of many crises. The “energy crisis” is one among the many crises met byhumankind. Value crises arise due to social, cultural, economic and intellectual differences. When one
speaks of the “Value Crises” it means the absence of positive, healthy values which pave way to a healthy
and harmonious social living. When more positive values confront an individual he falls prey to the“Value Crises”. The learner is educated to set his own priorities when there is a value crisis in such a waythat these do not affect the well being of the society. When the society values the learner as a gem, itis the burden of the learner as a gem, it is the duty of the learner to set a top priority of ‘Social Values’
because it is the society that directly and indirectly finances his education by direct and indirect taxes.
This should be made known to the learners and also their accountability to the society should never be
undermined.

Values in present day education

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Asia-Pacific Perspectives on Bioethics Education

Population expansion has led to a “knowledge explosion”. No one today respects weaklings and spinelesspersons, much less in a huge sub-continent like ours and elsewhere where everyone is waiting for his
slice of cake. The world belongs to those who know their jobs, are prepared to stand up for their rights,
assert themselves and work to secure justice. In today’s world no one can be secure by making theneighbour insecure, no country can be strong by making the neighbouring country weak. My security
and happiness depends much on the security and happiness of my neighbour. As Betrand Russell
observed, “it is co-existence or no existence”.
The present day education system is more “material” than “value” oriented. The curriculum is heavily
loaded with contents which have no values, and which cannot orient the student towards positive values
unless the teacher, who is an embodiment of all virtues sets himself as a role model to the students.
In brief the teacher is a “Precious Value” to his pupils. The policy makers may change, the educational
system may change, the management may change but the values taught and practiced by the teacher
should never change in order to have an everlasting positive, healthy impact on moulding the lives ofthe young future leaders of the country.

Conclusion
This study was conducted in November 1999 and the participants who have undergone thisexperimental procedure as “Subjects” are well placed in the society and are making a positive impact on
their respective fields of work. As we enter the twenty-first century and enter the third millennium therole of the classroom teacher becomes multifaceted due to the prevailing negative values in the society.
Jesus Christ, the wonderful Teacher says: “I know my sheep, and they know me”. It is the duty of every
teacher to know each and every student’s social, economic, cultural, intellectual and home backgroundand cater to the individual differences of the individual learners. Truly the parents are “living values” athome and the teachers are “living values” at school and to the society. It would be better to conclude byquoting Pandit Jawaharlal Nehru’s words: “if all is well in universities and colleges then all is well in thenation”. The third millennium is at the door step.

Bibliography
Shepphard. 1982. Basic Sociology.
Naik, J.P. 1985. Educational Planning in India. New Frontiers in Education, Vol. XXVIII No.1, Jan-Mar 1998,
p.p.98.
The Examiner, Sept.1998, pp.9.
Yojana, Dec.1998, pp.14-15.

Jaiswal, P.S. 1998. Ethics Essential for Value Education, The Examiner, Oct.30,.
Corden,D.S. Principles and Practice of Education.

Asia-Pacific Perspectives on Bioethics Education

Thorndike, R.L. and Hagen, E. 1970. Measurement and Evaluation in Psychology and Education, New Delhi,
Wiley Bastern Private Limited.

69

Bioethics education trials at Ateneo De Manila HighSchool in the Philippines in 2004-2005
Ester Estrella M. Abito, Milarosa
Librea and MaryAnn Chen Ng
Ateneo de Manila High School,
Philippines

Introduction70

Asia-Pacific Perspectives on Bioethics Education

The formal inclusion of bioethics issues in biology classes at the Ateneo de Manila High School started
in school year 2003-2004 through the holding of trial classes in bioethics in cooperation and funded by
Eubios Ethics Institute. As the school participated in this Bioethics Education Project coordinated by Dr.
Darryl Macer, the biology teachers handled trial classes on selected bioethics chapters/modules thatwere timely and relevant to the Biology curriculum (Macer, 2004).
In the school year 2004-2005, the Science and Technology Department of the high school mandated theteaching of bioethics as an integral and formal part of the biology curriculum. This move is in keepingwith the general provisions of the Constitution of the Republic of the Philippines that seeks, among
others, “to teach the rights and duties of citizenship, strengthen ethical and spiritual values, and develop
moral character and personal discipline.” Along the same vein, the formal integration of bioethics into
the fabric of the biology curriculum, implements the school’s philosophy and objectives of providing awell-integrated program for the development of the students’ ability, among others, “to make relevant
judgments and to discriminate among values… as responsible persons and productive members of
the community.” This development in the biology curriculum was aided by the provision of bioethics
materials and textbooks through the bioethics education project with Dr. Darryl Macer.

Bioethics in the biology curriculum
In the conduct of the actual bioethics trial classes, the biology teachers selected the bioethics chaptersor modules to integrate or use in their lessons from those available in Macer (2004). In table one, thespecific bioethics chapters or modules are matched with the corresponding topics of the Ateneo deManila High School Biology curriculum for the school year 2004-05 from June 2004 to March 2005.
Table 1: Bioethics Chapters/Modules’ Integration into the Ateneo de Manila High School Biology
Curriculum for the school year 2004-05.

Theme/Topic

Bioethics Chapter/Module

A. Introduction to Biology
Introduction to Bioethics

Chapter 1: Making Choices, Diversity andBioethics

B. Organisms are Made up of Cells
Chemical Basis of Life

Chapter 3: Genetic Privacy and Information

C. Organisms Reproduce
Reproduction

Chapter 8: Lifestyle and Fertility
Chapter 9: Assisted Reproduction
Chapter 11: Telling the truth about terminal
cancer

D. Organisms Grow and Develop
Genetics

Chapter 4: Testing for Cancer Gene
Susceptibility
Chapter 5: Human Gene Therapy
Chapter 10: Genetically Modified Food/Ethics
of Genetic Engineering

E. Organisms Use Energy
Respiration

Smoking and Fertility in Chapter 8 on Fertility
and Lifestyle

Circulation

Chapter 6: Brain Death
Chapter 7: Organ Donation
Chapter 12: Euthanasia
Chapter 13: AIDS and Ethics

F. Organisms Respond and Adapt to the Environment

Other Bioethics Sessions
In addition to the formal bioethics trial classes in the Biology classes, bioethics has also been the topic
of seminars, workshops and non-class activities with clientele including teachers and participants fromother high schools. Table two gives the details of these activities on bioethics.
Table two: Bioethics in other Activities in the Ateneo de Manila High School for the school year 200405.
Date

Participants

Activity
Seminar Workshop on current trends in Biology: Bioethics.

April 2004

25 Teachers (students ofan education graduate
programme course)

Bioethics topics covered were introduction to Bioethics,
ART, Cloning of human stem cells in South Korea, GMOs,
Organ selling in the Philippines, Organ Donation, theBioethics project of Dr. Darryl Macer

July 2004

Advanced Biology Class;
2 Regular Classes

Bioethics trial classes using Chapter 1, Introduction to
Bioethics – demonstration class for external observers:
Mr. Tetsuya Ishizuka, Project Officer for the Sasakawa
Peace Foundation, Japan, and Ms. Mary Ann Ng, country
coordinator for the bioethics project.

August 2004

Advanced Biology Class

Debate on GMOs, as supplementary activity to Chapter 10
on Genetically Modified Food/Ethics of Genetic Engineering

September 2004

All 14 Sophomore classes

Outbound Education in a Rainforest in Laguna province,outside Metro Manila – used as a take-off point for the
Bioethics Chapter on Ecotourism

Asia-Pacific Perspectives on Bioethics Education

Chapter 2: Ethical Limits of Animal Use
Chapter 14: Sustainable Development
Chapter 16: Ecotourism

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October 2004

December 2004

72

Asia-Pacific Perspectives on Bioethics Education

February 2005

11 Biology teachers fromdifferent schools in Metro
ManilaAdvanced Biology Class;
3 Regular Classes

Advanced Biology Class

A brief follow-up session in an Outreach Seminar of the
AHS Science and Technology Department for teachers
from various public high schools in Metro Manila; Majorityof these teachers were participants in the 2003 OutreachSeminar on the topic “Bioethics of Biotechnology”;
The teachers were provided free copies of the textbook
Bioethics for Informed Citizens Across Cultures, Dr. Darryl
Macer (Ed.)
Supplementary Bioethics class on Importance of Trees - tocapture and learn from the events of the previous week,
in particular, the devastation brought about by the recent
typhoons. This is a Bioethics session on the importanceof trees on the environment, in general, and on the wellbeing of men, in particular. This topic is a follow-throughon the previous topic on photosynthesis. Also, this is an
opportunity to capture a “teachable moment” that has
touched the lives of Filipinos at this time, and to learn how
to be better persons who are “stewards of God’s creations.”
Supplementary Bioethics class on Organ Selling in thePhilippines;
Utilization of Role Playing activity in the Chapter on Organ
Donation

Conclusions
This paper presented an update from the results in the first year of the bioethics class trials (Abito, 2004)
on the use of the materials from Macer (2004). The students welcomed the inclusion of bioethics acrossthe curriculum, and teachers were able to cope with the materials. The student reports were evaluatedand showed that they had learnt how to question the ethical aspects of many new technologies, whichshould enable them to be better decision makers in society. We hope that other schools will also include
bioethics into their teaching.

Acknowledgments
We appreciate the assistance of Eubios Ethics Institute in the project.

References
Abito, E.E.M. 2004. “Trials at Ateneo de Manila High School”. In Macer, D.R.J., ed., Challenges for Bioethics
from Asia. Christchurch N.Z.: Eubios Ethics Institute. pp. 597-601.
Macer, Darryl R.J. 2004. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios Ethics
Institute.

This year’s flowers are redder than last year - a brief
introduction of the bioethics project in the HighSchool affiliated to Beijing Normal University in
2003-2005
Liping Wang,High School Affiliated to Beijing
Normal University, China

Formation of the curriculum
Necessity for a offering bioethics curriculum
As life sciences develop rapidly, bioethics has been included into the scope of ethics education of
citizenship in various countries. Nowadays, China’s bioethics education is mainly confined to advanced
medical schools. In science education in ordinary high schools, teachers focus on cultivating students’scientific knowledge. From the aspect of humanity, Chinese traditional culture and ethics concentrates
more on individuals’ responsibilities to society and their country, holding that the pursuit of the Holy
Spirit is above anything else. All those have potential effects on students, some of whom feel puzzled
at the matters of life ethics. As China materializes the concept of scientific development and builds a
harmonious socialist society, bioethics can improve adolescents’ awareness of life. This will help to lay
the foundation for an ideal society where life is respected and treasured.
Applicability of bioethics education
Since the reform and opening up 20 years ago, China has obtained great achievements in various fields.
The development of economy and culture makes people ponder over the ethics of society. In addition,
the progress of society demands commensurate maturity of social ethics. In today’s China, the rapid
development of bioethics matches the demand on itself.
As a famous school with a 100-year history, our Affiliated High School has rich resources of education,affiliated to Beijing Normal University (BNU). It carries out external exchanges frequently and has
established cooperative relationships with many institutions, which paves the way for offering abioethics curriculum in our school.
(a) Advanced Educative Visions The High School makes various resources accessible to its students.
It is responsible not only for their higher education, but also for their lifelong development.
Although bioethics is not a subject of the entrance examination, fundamentally it cares about
juvenile’s growth and is significant in helping to build an ideal society. With this in mind theschool values greatly the bioethics curriculum.
(b) Rich educative resources In the Department of Biology, half of the postgraduates and the1

http://www.bjsdfz.com (in Chinese)

Asia-Pacific Perspectives on Bioethics Education

The existence of life is a precondition for all human activities and the quality of life is the foundation of
the progress of humankind. Life education, therefore, is an eternal educative theme. Bioethics invites
the values and principles of ethics to test how human activities influence human life, animal life, plantlife and ecology. In September 2003, the High School Affiliated to Beijing Normal University1 as anexperimental school in the mainland of China, took the lead in introducing bioethics, a new subject, to
the Chinese high school system (Zhuo, 2004).

73

teachers have gone abroad for further study. They have great potential to conduct teaching andresearch. The knowledge and skills they master are supplementary to each other. Separately,
they study zoology, organic embryology, ecology, environment, education and so on. Further,
there are teachers who specialize in combining class teaching and information technology. Someteachers are members of animal protection associations. In brief, teachers in the department of
biology are capable of offering the new curriculum.
(c) Emphasis on management The headmaster of the school looks into the subjects and has
identified bioethics as a featured subject of the school. The management gives full support to thebioethics curriculum, financially and materially. In order to promote the sustainable developmentof bioethics, we are also active in offering opportunities for external exchanges.

Implementation of the curriculum

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Asia-Pacific Perspectives on Bioethics Education

The organization of the Bioethics Curriculum is structured as an optional subject for Senior II students (atthe age of 17). Bioethics enriches students’ knowledge of biological science. Having acquired relevant
knowledge from biology, a compulsory subject, the students now gain further understanding of therelationship between biological science and society, and sense life education.
The time of the lecture is 15: 25-16:45pm on Wednesdays for 80 Minutes. The course is given for one
semester. To facilitate interaction, class size is limited to 30. In the first year, we used Bioethics for
Informed Citizens across Culture (Macer, 2004), provided by the Eubios Ethics Institute (Zhao, 2004). The
teaching experience of the first year told us that some chapters of the original textbook were not always
suitable for our students. Due to the fact that different nations have different economic and cultural
backgrounds, our students have difficulty in comprehending some cases and metaphors. As a result, inthe second year, we used the English textbook as a framework and began to compile teaching materials
more suitable for Chinese students.
The teachers of the department of biology have primary responsibility for lectures. Teachers of politics
and English, along with the specialists from other institutions, take an active part in co-ordinating the
programme as well. Because there is no domestic precedent and relevant experience, teachers choose
the topics freely on the basis of their familiarity with the students and their respective specialties. Everylecturer will be responsible for two or more topics in which they are interested (See Table one).
After the first round of experiments, we seriously listened to the feedback from the students. Somestudents pointed out that they didn’t like the depressing topics, like Palliative Care. Some said that such
topics such as testing for cancer gene susceptibility were not closely connected with their own daily life
styles. The concept of ecotourism was not so familiar. On the other hand, they were interested in ethicalproblems in association with cloning and embryonic stem cell research.
Some students were interested in the recent events, such as SARS and Avian Bird Flu. The question of
drug abuse was also raised by some of our students. Based on the needs of the students, we adjusted our
curriculum the following year. We selected those topics that were more interesting and linked closely toreality. More teachers, with their specialties, were encouraged to join. (See Table two)
Table 1: Curriculum for the Semester 2003-2004
Topics

Lecturers

Dates

1. Making Choices, Diversity and Bioethics

Su Baoqi

September 10, 2003

2. Genetic Privacy and Information

Fu Jinhua

September 17, 2003

3. Brain Death

Kuang Li

September 24, 2003

4. Organ Donation

Yu Yuan

October 8, 2003

5. Ecotourism

Li Jianzhi

October 22, 2003

6. AIDS and Ethics

Zhuo Jing

October 29, 2003

7. Assisted Reproductive Technology

Fu Jinhua

November 5, 2003

8. Genetically Modified Food

Gu Yongmei

November 12, 2003

9. Palliative Care

Kuang Li

November 19, 2003

10. Euthanasia

Zhuo Jing

November 26, 2003

11.Testing for Cancer Gene Susceptibility

Yu YuanDecember 3, 2003

12. Animal Rights

Li Lei

December 10, 2003

13. Sustainable Development

Li Jianzhi

December 17, 2003

14. About Life

Wang Bin

December 24, 2003

Topic
1. Introduction of Bioethics
2. Genetic Privacy and Information
3. Brain Death
4. Organ Donation
5. AIDS and Ethics
6. Human Dry Cell Research and Ethics
7. Genetically Modified Food
8. Euthanasia
9. Animal Rights
10. Treasure Life and Refuse Drugs
11. Human Plague
12. What to do before the Clone?
13. Assisted Reproductive Technology

Lecturer
Fu Jinhua
Fu Jinhua
Kuang LiYu YuanZhuo Jing
Liu Xiaoyan
Gu Yongmei
Liu Xin
Li Lei
Li Jianzhi
Wang Hao
Bai Wenbin
Fu Jinhua

Dates
September 8, 2004
September 15, 2004
September 22, 2004
October 6, 2004
October 13, 2004
October 20, 2004
October 27, 2004
November 3, 2004
November 10, 2004
November 17, 2004
November 24, 2004
December 15, 2004
December 22, 2004

As a form of teaching we aim to combine explanation and discussion. Teachers provide basic materials
and explain the relevant knowledge concerning biology. After that, the students will be encouraged to
discuss the issues of Chinese legislation and prospects in the fields of AIDS Prevention, Organ Donation,
Human Embryonic Stem Cells and so on.
Assignments are important for appraisal. Students are required to write three articles, either in English
or in Chinese. Grades are based on their participation in the lectures and the quality of writing

Achievements and reflections
After one year of teaching, we have realized that life education is a combination of science and sentiments.
Apart from selecting the typical and touching cases, we should pay attention to the knowledge ofscience, because science knowledge can change students’ behaviour and attitudes. Teachers should
allow students to discuss and express their ideas freely and fully. On the basis of discussions and idea
expressions, teachers make conclusions accordingly. So, in the next year, teachers not only transmit
the knowledge, but also organize students to discuss the typical cases. In that process, students areable to think about the matter of ethics and make their own judgments. The bioethics curriculum does
perfectly in encouraging the initiative of teachers and students. Teachers have displayed more picturesand visual materials. Some lectures have students play roles. We organize our students to make surveys(e.g. public opinion on cloning) and visit exhibitions (e.g. anti-drug campaigns).
Feedback from the students showed that they are attracted to the bioethics curriculum. They gained
a lot from instructive lectures and the free discussion in the classes. Because quite a few teachers taketurns to give lectures, students have the opportunity of learning various teaching styles in a short time.
In addition to discussions with teachers and classmates, students also exchange ideas with their parents,
which makes family education a part of school education.

Asia-Pacific Perspectives on Bioethics Education

Table 2: Curriculum for the Semester 2004-2005

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By studying bioethics, students not only get to know the most sophisticated science and technology,
but also receive a profound life education. They begin to realize the significance of science, society andlife. They gradually understand how precious life is, and what responsibilities they should take in society.
Bioethics enables students to learn “how to behave, how to understand, how to co-exist, and how tosurvive”, which paves the way for their lifelong development.
By getting involved in this international project, every teacher benefits from it. First of all，they obtainfirst-hand materials. Besides, the project heightens the prospect for their professional development. Ourteachers have published some papers on bioethics, which has had some influence in China. Mr. Liu Hu, aheadmaster, wrote a paper Bioethics, a New Curriculum of Life Education published in the Fundamental
Education References, an academic magazine of the Chinese Ministry of Education. Bioethics curriculum
provides a stage for teachers to collaborate and communicate with foreign participants. Second,teachers better understand their students. Teachers have learned that not only are students willing tolearn science, they are also eager to know more about society and express their ideas about the reality.
Finally, bioethics curriculum promotes our educative vision of STS (Science, Technology, Society). Ourteachers have begun to transmit the thinking of bioethics on purpose.
In short, through the joint efforts of teachers and students, the teaching system of bioethics in theschool has initially come into being and will enjoy further development.

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Suggestions
The 21st century has witnessed the rapid development of life sciences. New terms like the Post-genomic
Era, Human Brain Project, Molecular Neurobiology, Systems Biology, Bioinformatics, Nano-Biology,
Biochip, Biological Motor, and so on, have come up at an amazing speed. So bioethics needs to refresh
itself in contents and reflects the features of the times.
Because every country has its own conditions, such as the level of scientific development and language,
uniform textbooks will cause the difficulty in understanding. Therefore, we suggest, with basic principles
observed, every country should develop its own subjects in accordance with their national conditions.
Different institutions should strengthen their mutual exchanges and collaborations and assimilate eachother’s experience. The healthy development of bioethics cannot be separated from the joints efforts
of different bodies. More people should be encouraged to learn bioethics. Pupils in elementary schools
and college students are all targets of the education.
In conclusion, the success of bioethics curriculum shows that it has a bright future. We believe that we
can do better and play a more important role in the development of scientific culture.

Acknowledgments
This paper is presented on behalf of all members of the school. We appreciate the assistance of Eubios
Ethics Institute in the project.

References
Macer, Darryl R.J. 2004. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios Ethics
Institute.
Zhuo, J. 2004. “Trials in the Middle School attached to Beijing Normal University”. In: D.R.J. Macer, ed.
Challenges for Bioethics from Asia. Christchurch, N.Z.: Eubios Ethics Institute. pp. 606-7.

The actualities and prospect of bioethics education ina Chinese middle school*
Fu Jinhua
The High School Affiliated to
Beijing Normal University, China

Introduction

Curricular provision of the optional courses
At the beginning of the last term, our school totally offered twenty four optional courses to the grade
two students (N=725). These included calculus, literature, Japanese, painting, dancing, and so forth.
Every teacher must make an introduction about the course which she took charge of in the auditorium.
So every student could get some necessary information and decide to choose their favourite course.
When I finished the introductory presentation on bioethics, the response was very strong. The students
showed much enthusiasm. More than 200 students of the 705 students wanted to select this course.
Due to the limitation of the classroom accommodation and the quota of 30 people, only 30 students
can seize the opportunity to join in this group. Even though, the result encouraged us to squeeze fifty
students into our class. In fact, it’s a little crowded in the classroom, but the students felt they were fairly
lucky to study bioethics.

Curricular design of bioethics
The material we used is Bioethics for informed citizens across culture (Macer, 2004) supplied by the
Eubios Ethics Institute, including sixteen chapters. It provides a new angle of view for us, so we used
this book for reference. But the length of every chapter is not very long, and few cases are available.
After considering the interest and the intellect of the middle school students, we selected fourteen
topics and added some real cases to each lecture, which closely accorded with Chinese conditions. In
addition, since the book is in English, the student’s wasted much time in looking up the new words intheir electronic dictionaries in the class. We are all hoping for Chinese translations.
We devised a variety of teaching methods, including analyzing cases, discussing, collecting questionnaires,
demonstrating PowerPoint files, watching visual materials and role play as teaching aids. So these means
make up for the shortcomings of teaching theory simply and make the teaching course more lifelike
and visual. Furthermore, through these methods, the students can combine knowledge with social life.
The purpose of this project is not to gain a high score, so there is no examination required in bioethics.
Therefore, the students can write some essays at the end of the term and get their credits.

* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005
1

Previous paper in this volumeAsia-Pacific Perspectives on Bioethics Education

At present, as described by Ms. Wang1 we have carried out several bioethics trials in our Chinese middle
school from September 2003. With the development of this project, we have accumulated more andmore experience and concluded the lessons from the practice. In this paper I supplement some of theinformation provided in the previous overview. We can ask does the material assembled in Bioethics for
informed citizens across cultures (Macer, 2004) adapt well to Chinese middle school students? What did
the students learn in this class? Is this subject beneficial to the students and does it have an influenceon their behaviour, life view or value view? As the coordinated school, what does this project bring us?
I also want to share some comments from students.

77

Example feedback from the teachers
Miss Liu Xin: “The text of “euthanasia” first presented the concept of euthanasia and the views ofdifferent religions on this question. Then it described some important historical events about euthanasia,
especially the Nazi regimes’ big massacre. At last, it presented the statutes about “euthanasia” in the
Netherlands and other states.
This text is a good reference for my teaching, and in my lesson, I spoke of almost all its content to thestudents. However, I think the contents of this text are too little and too simple, because this lesson isintended for the middle school students and it will cost them two class hours. I think the contents, forexample the religions views are distant to the condition of China and the students’ everyday life. So, I
think it’s fit for reference material for Chinese middle school and primary school.”78

Asia-Pacific Perspectives on Bioethics Education

Liu Xiaoyan: “The studies on embryonic stem cells become more and more popular. On the one side,
there are many people who need this technology, so the market on this field is broad. On the other side,some people realized that embryonic stem cells are also humans so thought that the study on themshould be banned. The study had involved in bioethics problem. In some countries, people who arein poverty sell embryos and ovum. Bioethics about this field is not included in our book. We need toknow how to balance different benefits, risk about this. So we think this part should be included in our
project.”
Wang Hao: “I taught about SARS and the bird flu. I think we should introduce wider knowledge tostudents and help them to learn more background discussions about bioethics. Then, bring forward
some profound and recommendable issues to students. Meanwhile, establishing the communication
between students and teachers is very important, which can promote information’s transfer and share.
Our responsibility is to spirit up students’ thinking on bioethics and helps them to establish correct
evaluation on bioethics.”
Fu Jinhua: “I taught genetic privacy and information as an elective course. The goal of this course is forstudents to learn not only the basics of genetics but also to be updated on the latest advances in genetic
engineering. Furthermore, this course aims to stimulate the students’ interest in genetic engineeringand cultivate their creativity as part of character building and ethical learning”

Example feedback from the students
Liu Ruirui: “Every scientific progress would bring some problem to our society. Brain death is one ofthem. Maybe it is difficult to receive; however, I support it. You can’t believe that your family or friend
who is still breathing are said to be dead; you can’t believe that your family member or friend whoseheart is still beating are diagnosed that he has no chance to wake up. But please face to the fact, he hasgone. He won’t move or talk forever. We waste a lot of things and money without using brain death.
Some people think they prefer their body to be whole when they died. I have no right to evaluate.
But some patients can get new organs to save their lives. In fact, these people more prefer keeping
the hopeless body than saving other patients lives. Certainly, I must recognize the problems which arebrought by brain death at the same time, such as the illegal trade between the doctor and the patient.
However, brain death is a new concept to the majority of the people. We must make rules to prevent thebad phenomenon rising. Brain death can benefit the society. I hope brain death will be received by all
the people as soon as possible.”
Zhang Qian: Firstly, I think bioethics is a comprehensive subject. It combined the biology and theethics together. My classmates and I both think this class is very interesting. It’s suitable for the seniorschool students. It tells me some knowledge that also advanced what I need to know about my required
subjects and broadens our minds. Secondly, through studying the animal right and the sustainable
development, I think the human being should get along with the animals and the environment
harmoniously. In addition, I hope teacher will teach us from easy to difficult problems, and give us moretime to discuss and debate. Through the feedback from the students, it’s easy to see that they have great
enthusiasm on this subject. And they thought this course is helpful in forming a scientific worldview. In
the class, we mainly discussed in groups. In this way, the students can learn from others. They hope that

bioethics will become more popular among the middle school students.”

The relationship between biology and bioethics education
As we all know, in a Chinese high school, biology is a required course and a compulsory course forstudents who want to pass the college entrance examination. Innovators of biology education haverealized the importance of ethics. When they revised the material, they permeated these ideas into
the new materials. For example, genetic privacy and the information, genetically modified organisms,
appeared in the required books. Genetics is important in our regular syllabus for issues such as
variation, and AIDS for immunity. In fact, bioethics not only does well to the students but also benefits
the teachers. This information helps them to prepare an attractive lecture, which especially helped the
young teachers. Bioethics and biology are combined to realize our educative objects and our conformityof science, technology and society.
To our school, this supplied a good opportunity to carry out life education. The principal sang high praise
for this course and wrote a disquisition about bioethics as the new curriculum in life education. This was
published in the basic education review in July 2005. I think this project will be used continuously andwill become more popular for Chinese students.

Macer, Darryl R.J. 2004. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios Ethics
Institute.

Asia-Pacific Perspectives on Bioethics Education

References79

To treasure your life, refuse drugs*
Li JianZhi
The High School Affiliated to
Beijing Normal University,
China.

Learning target
In recent years, drug abuse has become a common problem around the world. Illegal drugs have spreadto more than 200 countries and five continents, reflecting a tendency of further abuse. Most worrisome
is that teenagers are the main group taking drugs. We cannot wait for the authorities to improve drugawareness. The main targets of my lessons in the bioethics course in China were: learn what drugs are;know the potential harm of drugs; reasons for adolescent drug abuse; spread the message to keep
children away from drugs; and consider ethical issues involved in drugs.

80

Asia-Pacific Perspectives on Bioethics Education

Teaching process
Introduction of the subject
The poppy, originally a beautiful plant has become a flower of evil since people extracted a kind ofwhite powder from its flower. There is a saying that “the most poisonous snake has the most beautiful
appearance”, and in this case a most poisonous flower is the most beautiful looking (Figure 1).
Figure 1: poppy flowers
True colour of drugs
Illegal drugs, a kind of special medicine, are controlled
and mandated by the state as they tend to make people
addicted after the abuse of the substances. Meanwhile,, thecharacteristics of drugs are poisonous, addictive and illegal.
The common drugs are opium, heroin, Methamphetamine(ice), dancing outreach, Morphine, marijuana, etc. Some
pictures were shown to the class (Figure 2). I asked a question
to make students think: “Is pesticide a drug? Cigarettes andalcohol can make people addictive, are they drugs?”
Figure 2: Pictures of some common illegal drugs.

HeroinOpium* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

		

Dancing Outreach		Morphine

MarijuanaHarm of drugs
The harm of drugs can be summed up as “self-destruction, family-breaker and society-destroyer”. I
told them: “When you appreciate bewitching poppy flowers, death is looking at you too.” In May 2000,
Ms. Whittier, a British female student, died of heroin overdose. Her body was found on the day of her
father’s birthday, three days after her death. She died in a kneeling position, seemingly as though shewere questioning herself and apologizing to her parents, confessing to God, charging the drugs andcautioning others (See Figure 3).
Figure 3: Observe the pictures:												Kneeling Position when Ms. Whittier died		

Asia-Pacific Perspectives on Bioethics Education

Methamphetamine(Ice)

81

82

Asia-Pacific Perspectives on Bioethics Education

The character in the first picture once lived in a good house and didn’t worry about food and now he isseen begging alone in the streets. The second picture depicts a scenario such as this: taking drugs -->getting into debt --> stealing --> robbing --> going to jail.

Consider the figures
According to an investigation by the US government, some 94% of money for drugs was gained from
criminal activities. Statistics from Kunming, China, reveal more than 80% of the city’s drug abusers havecommitted crimes. Drug abuse is a complex social phenomenon and many ethical problems occur
because of drugs and drug abuse. I asked further questions:
Question 2: I.V. drug users are a high target group of HIV infection. According to statistics, morethan half of HIV-infected people are victims of drug injection. So, drug clubs are founded in othercountries to provide clean needles for drug injection addicts. Do you agree with this method?
Question 3: Currently, the Ministry of Health stops “Surgery therapy in drug dependence” inan emergency. This method is curing drug addiction by destroying people’s nervous systems.
However, a likely side effect is that it will lead to feelings of indifference for the person andeverything around them. In addition, the short-term effect of the surgery is favourable but
the long-term effect is difficult to estimate presently. Do you think “Surgery therapy in drug
dependence” should carry on?
Question 4: Morphine, Dolantin and anodyne are generally used in hospitals. For relieving thepain of patients, doctors often use Dolantin and in turn some patients become addicted to the
medication. Should the doctor bear the responsibility?
From these case studies, students realise that not only doctors, but also health policy is responsible forthe health of humans, which has implications involving profound ethical principles. There are many
similar ethical matters in life. Bioethics is not to provide a definite and simple solution for them. However,its discussion and introspection for those matters help us figure our behaviour with a prudent attitude
when we encounter similar matters later on.

How far are drugs from us?
It is a core and end-result of drug education. The Chinese National Drug Abuse Control Committee
conducted a statistical survey of the age structure of Chinese drug abusers in 2004. The result is asfollows in Figure 4:

2.60%
12.30%
Under 35
35－60
Over 60
85.10%

Figure 4: Age Structure of Chinese Drug Abusers
Question 5: What conclusion can you draw from the above figure? What are the reasons forteenagers taking drugs? Analyze the case: Wang, a female aged 14 doesn’t work hard at school
and often spends time with juvenile delinquents. Her curiosity caused her to experiment withhard drugs from a group of drug addicts.

Question 7: Your parents are afraid that you will take drugs because one of your friends does andthen they privately test your urine for substance abuse. Can you accept this?
Question 8: A friend handed you a cigarette at the party. You didn’t want to smoke but wereafraid of losing face, or your friends. What will you do?
Question 9: Do your classmates smoke? How do you suppose you could persuade your friend to
give up smoking?
Question 10: Under what condition will you meet people who may tempt you into taking drugs?
What should you do to say “no” to drugs?
Based on the analysis of adolescent drug abuse, students were able to find corresponding preventive
measures for drug abuse and showed the ultimate target of drug control education by the questions
above.

Review
The classes revealed that students are interested in learning and are concerned about drug education.
Students not only acquired basic knowledge on drugs and drug addiction, but they enhanced theirawareness of the potential harms of drugs. Furthermore, they learnt a more scientific approach tothinking. This meant that they were more willing to express their opinions in class. I gave several example
questions in this paper. In addition some students made a poster for drug control as an assignment.

Asia-Pacific Perspectives on Bioethics Education

Question 6: Is it correct that teenagers try anything unknown? (It enabled students to fully viewthe matter on drug abuse.)

83Organ transplants and organ donation*
Yuan Yu,
The High School Affiliated to
Beijing Normal University, China

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Asia-Pacific Perspectives on Bioethics Education

I undertook the teaching of a special topic “organ transplants,” which is a part of the school elective
course of “Ethics and Moral Standards” in 2004-2005. The following is the format of the teaching design
I used. Students might be very familiar with the words “organ transplants”, easily giving many examples.
However, they have little knowledge about the definition of “organ transplants” and the conditions oforgan transplantation or whether the transplant will be approved by our moral standards. Therefore, I
worked in accordance with the student’s knowledge level, based on the teaching material “Bioethics for
informed citizens across cultures” (Macer, 2004). I carefully designed the teaching process, making fulluse of the case studies and relative background materials.
The teaching procedure I used was to put forward several questions for discussion. For example:• Did you ever have a blood transfusion or make a blood donation? Can a blood transfusion or donation
be considered an organ transplant?
• Do you know actually what an organ transplant is? When did it begin?
• What problems should be solved during the organ transplant?
• What is the key factor of a successful organ transplant?
These questions allowed me to gauge the concept further and I could therefore, describe the concept,
history and current situation of organ transplants. This engaged the students and they continued to ask
questions. I introduced some background knowledge, such as:a) History of organ transplants and overview of development;b) Variety of organ transplants;c) Key factors of a successful organ transplant;
Whether an organ transplant succeeds depends on many factors. The stitching of the blood vessels andimmune rejection are the most important problems. The break-through of the brain death concept,
overcoming the obstacle of tissue matching and developments of the new immune inhibitor are also
important.
d) Organ transplants and ethics
Do ethical standards allow us to obtain a survivable organ and transplant it to another person? Are any
ethical problems encountered? Regarding our students, I arranged a debate and asked both sides toback up their views with sufficient evidence.
The students who argued in favour of transplants firstly put forth data evidence. A survey undertaken
in Beijing, Shanghai and Wuhan indicated that organ transplantation is regarded as a popular concept.
Eighty seven percent viewed this kind of medical technology as promoting the well-being of humankind,
72% expressed the view that if there is a need and a possibility, they will receive organ transplants
and 70% expressed their willingness to donate their own organs. For this reason, they deemed organtransplants a medical practice favourable to human health that can be approved by ethical standards.
* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Organ transplantation is a noble medical practice and a modern medical method to help heal thewounded. For a sick patient, organ transplantation will bring the possibility of prolonging their lives.
The students opposed to the practice argued that organ transplantation destroys human integrity. This is
influenced by Chinese traditional culture and the theory of Chinese medicine, so people generally thinklife should always be complete and that dissecting the corpse is similar to an act of treason. Harvestingorgans from a living people is even more objectionable, in their view. Secondly, it is a kind of superior
technology, expensive, and some patients won’t like the idea of it. There will be many extra charges suchas nursing, monitoring and immunosuppressive medicine.
Thirdly, in the case of a shortage of organs, organs could be harvested from other categories of living
beings. More and more problems appear when it comes to harvesting organs from other kinds of living
beings. What’s more, it can break the harmony that exists. Meanwhile, transplanting animal organs may
pass animal viruses to humankind, such as mad cow disease and AIDS.
After viewing arguments from both sides, everybody generally supported the “pro” view. Our students
not only understood the process of organ transplantation and the ethical problems which arise, butthey also showed their good character when discussing these issues. They showed their readiness toaccept an organ transplant and they accepted that they would donate their own organs if they are reallyneeded.

At present, many patients die while waiting for organ transplants. If several patients urgently need
the same organ at the same time, but only one can be supplied, a critical question is how should thetransplant continue? Should we offer the organ to the critical patient or a wealthy merchant or powerfulbureaucrat? It is difficult to make a decision on the fair distribution of organs. Furthermore, the collection
and donation of organs is tricky and is a pertinent ethical and moral question.
Students were educated that in order to guarantee that organ transplants can give hope to a new life
for critically ill patients and benefit human health. The World Health Organization made guidelines forhuman organ transplantation at the 40th World Health Assembly in 1987. There is a relatively objective
medical and social standard for one who has priority to transplant organs. At the same time, in thecourse of organ donation, we must follow the principle of free will.
Moreover, problems always arise (for example, buying or selling organs) that conflict with the law
and brain transplant problem. Due to time restraints, I cannot give details about all of these complex
issues.
Then I introduced some legal cases regarding organ transplants and recommended some reference
books to help students with their further understanding of the issues and ethical standards.

Student achievements
Through the study, students have not only developed an understanding of ethical issues but they havealso grasped the way to recognise and analyze problems. They have a deeper understanding about thefollowing:a) Follow the principle of free will while donating the organ. The donor has the right of informed
consent;b) For the organ trade phenomenon in the society, we must strengthen the sense of selfprotection;c) There are certain conditions and age limits for organ donation that should be abided by legal
regulations.

Asia-Pacific Perspectives on Bioethics Educatione) Source of organs

85

Acknowledgments
Here I must express my gratitude to Professor Darryl Macer for providing the teaching materials to help
our students understand the relationships between organ transplants and ethics standards, from asensible to a rational level.

References86

Asia-Pacific Perspectives on Bioethics Education

Macer, Darryl R.J. 2004. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios Ethics
Institute.

Responses to bioethics education in selected schoolsin Tamil Nadu, India*
Jayapaul Azariah and Preethi
Azariah,All India Bioethics Association,
India

The first author taught bioethics in the Faculty of Life Sciences at the University of Madras prior to hisretirement. University students were very interested in bioethics, but it remains an interesting question
as to how high school students will approach bioethics. We joined the project, launched by Darryl
Macer, of the trials of the textbook “Bioethics Education for Informed Citizens across Cultures” (Macer,
2004a). In response to a global need for such materials, that textbook was produced for use in school
and university classes to teach about bioethical issues. For this purpose, it is necessary to assess theneed of each sector of a society. This paper presents some results of trials from selected schools in Tamil
Nadu, India.
During 2004, an attempt was made to test the text across a range of disciplines and social strata so as tobetter picture the bioethical mindset of students and elders. The results are reported in this paper in the
sharing of teaching materials and class trials to teach students to cope with bioethical, environmental
and medical ethics issues.
Two types of questionnaire were given to the participants of the class trials: (i) a list of about 28 topics
which are of bioethical importance and a copy of the response sheets found in selected topics from thebook “Bioethics Education for Informed Citizens across Cultures”. The respondents were also asked toprioritise their current need in acquainting themselves with any five of the 28 bioethical topics listed.
The paper provides comparative results of the class trials.

Corley Higher Secondary School (Tambaram, Chennai city, India)
Dr. Jayapaul Azariah conducted trials on the preferences for bioethics topics expressed by students andteachers in several schools in India, following short visits and introductory lectures using the bioethics
textbook. Further analysis of the student reports from classes is ongoing. The medium of Instruction inCorley School was both Tamil/English and the first school visit was on 19 March 2004. Results of trials inclass with N=61 students and 1 Teacher are in Table 1.
The medium of instruction for bioethics was English. The procedure used was that a handout was given
to each student. They were asked to listen to the guest lecturer (Jayapaul Azariah), who then explainedthat they need not write their name but only their class on the feedback form. They were asked toanswer the first column, which tested their awareness and familiarity with the topic. Then I explained indetail what each topic meant and gave them an example. Then they were asked about their choice anddesire to study each topic. Then they were asked to mention if the subject was difficult to understandor easy.

* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

Introduction

87

Table 1: Results from Corley High School (%)

88

Asia-Pacific Perspectives on Bioethics Education

No

TopicsHave youheard about
it?

Would you liketo study these
topics?

Yes

No

Yes

No

Yes

No

Is the subject
understandable?

Teachers:
Can youteach?

1

Artificial Insemination,
Sperm, Egg & embryo
donation

37.8

62.2

54.1

45.9

49.2

50.8

Yes

2

Surrogacy

13.2

86.8

42.6

57.4

44.2

55.8

Yes

3

Somatic Cell Gene
Therapy

23.0

77.0

70.5

29.5

50.8

49.2

No

4

Germ-line Gene Therapy

18.0

82.0

39.3

60.7

37.7

62.3

No

5

Human Cloning

65.6

34.4

65.6

34.4

49.2

50.8

Yes

6

Eugenics

22.9

77.1

40.9

59.1

36.1

63.9

Yes

7

SARS Severe Acute Resp.
syndrome

68.8

31.2

83.6

16.4

72.1

27.9

Yes

8

Benefits Versus Risks

21.3

78.7

49.2

50.8

52.4

47.6

Yes

9

Animal Rights

59.1

40.9

68.8

31.2

65.5

34.5

Yes

10

Intrinsic and Extrinsic
ethical factors overanimal use

14.8

85.2

29.5

70.5

27.9

72.1

No

11

Genetic Testing &Privacy

19.6

80.4

45.9

54.1

45.9

54.1

Yes

12

Testing for Cancer Gene
susceptibility

40.9

59.1

60.7

39.3

47.5

52.5

Yes

13

AIDS Testing

88.5

11.5

83.5

16.4

83.6

16.4

Yes

14

The Heart Transplant

54.0

46.0

77.0

23.0

67.2

32.8

Yes

15

Ethics and Diving Cars

27.8

72.2

44.3

55.7

45.9

54.1

No

16

Ecotourism and Ethics

8.2

91.8

19.6

80.4

27.8

72.2

Yes

17

Sustainable
Development

21.3

78.7

70.5

29.5

64.0

35.0

No

18

Euthanasia

21.4

78.6

39.3

60.7

32.8

67.2

No

19

Telling Truth about
Terminal Cancer

50.8

49.2

59.0

41.0

62.3

37.7

Yes

20

Autonomy

37.7

52.3

53.9

36.1

52.5

47.5

Yes

Yes

No

Yes

No

Yes

No

21

Justice

73.7

26.3

65.5

34.5

59.1

40.9

No

22

Making Choices, diversity& bioethics

31.2

68.8

45.9

45.1

42.6

57.4

No

23

Genetic Engineering &
Food

42.6

57.4

57.4

42.6

55.7

44.3

Yes

24

Reproduction andFertility

75.4

24.6

70.5

29.5

57.4

42.6

Yes

25

In Vitro Fertilization (IVF)
Technology

8.2

91.8

52.5

47.5

47.5

52.5

No

26

Bioethics

34.4

65.6

77.0

23.0

69.2

32.8

No

27

Water Management

70.5

29.5

90.2

9.8

77.0

23.0

Yes

28

Assisted Reproductive
Tech

24.6

75.4

57.4

42.6

52.5

47.5

Yes

4
17
18
25

Germ-line Gene Therapy
Sustainable Development
Euthanasia
In Vitro Fertilization (IVF) Technology

The most popular topics the students would like to study (they could chose five each) were:
1
2.
3.
4.
5.
6.
7.
8.
9.

SARS			Animal rights		
Heart transplant		
Cloning			Water Management
Bioethics		
Reproduction & Fertility
Justice			
Genetic Engineering

59.2%
54.4%
41.6 %
36.8%
32.0%
20.8%
20.8%
20.8%
19.2%

This pattern is different from what was reported from the other Far Eastern countries such as thePhilippines or Taiwan at the Fifth Asian Bioethics Conference (Macer, 2004b). The school is an English
medium school but students have classes explained in Tamil most of the time. It is in between an English
medium and Tamil medium school. Most students belong to a lower middle class social group or evenlower. The pattern may change in a school with a different social class background. There is also wide
diversity inside each school.

Pulicat National School (Ponneri district, Tamil Nadu, India)
Pulicat National School, Pulicat, Ponneri District, was visited first on 28 June 2004. Six teachers wereinterviewed, and the results are in Table 2. The language of instruction at this school is both Tamiland English. Teacher and student preferences for topics are presented below (Table 3 for student
preferences).

Asia-Pacific Perspectives on Bioethics Education

In addition there were open questions, and the responses to the question: Which five topics you would
like to study? There was only one class teacher and her response is given at the last column of the
response sheet (Table 1). Her most favourite subjects were (Topic Number and name):

89

In Pulicat the responses to the question: Which five topics you would like to study? found that forteachers, the most popular topics that they would like to study were: Heart Transplant 67 per cent,Water Management 67 per cent, Artificial insemination 50 per cent, Sustainable Development 50 per
cent, Germ line gene therapy 33 per cent, SARS 33 per cent, AIDS testing 33 per cent. The most popular
topics the students (N=27) would like to study (they could chose five each) were:90

Asia-Pacific Perspectives on Bioethics Education• Euthanasia 			• Sustainable Development• Bioethics			• Water Management		• SARS				• Animal Rights			
• Justice				• Autonomy			• Human Cloning			• Germ line gene therapy		

66.6 per cent62.9 per cent59.3 per cent48.2 per cent29.6 per cent29.6 per cent25.9 per cent22 per cent14.8 per cent14.8 per cent

Table 2: Preferences among teachers at Pulicat National School (N=6, results in %)No

TopicsHave you heard
about it?

Would you like to
study these topics?

Can you teach?

Yes

No

Yes

No

Yes

No

1

Artificial Insemination, Sperm, Egg &embryo donation

100

0

83.3

16.7

66.7

33.3

2

Surrogacy

83.3

16.7

100

0

66.7

33.3

3

Somatic Cell Gene Therapy

83.3

16.7

83.3

16.7

66.7

33.3

4

Germ-line Gene Therapy

83.3

16.7

83.3

16.7

83.3

16.7

5

Human Cloning

83.3

16.7

83.3

16.7

83.3

16.7

6

Eugenics

66.7

33.3

83.3

16.7

66.7

33.3

7

SARS Severe Acute Resp. syndrome

100

0

83.3

16.7

100

0

8

Benefits Versus Risks

33.3

66.7

33.3

66.7

33.3

66.7

9

Animal Rights

16.7

83.3

83.3

16.7

50

50

10

Intrinsic and Extrinsic ethical factors
over animal use

16.7

83.3

50

50

50

50

11

Genetic Testing &Privacy

66.7

33.3

83.3

16.7

66.7

33.3

12

Testing for Cancer Gene susceptibility

50

50

83.3

16.7

83.3

16.7

13

AIDS Testing

83.3

16.7

83.3

16.7

83.3

16.7

14

The Heart Transplant

100

0

83.3

16.7

83.3

16.7

15

Ethics and Diving Cars

16.7

83.3

33.3

66.7

66.7

33.3

16

Ecotourism and Ethics

66.7

33.3

66.7

33.3

66.7

33.3

17

Sustainable Development

83.3

16.7

66.7

33.3

83.3

16.7

18

Euthanasia

33.3

66.7

100

0

83.3

16.7

Yes

No

Yes

No

Yes

No

19

Telling Truth about Terminal Cancer

50

50

50

50

33.3

66.7

20

Autonomy

100

0

83.3

16.7

66.7

33.3

21

Justice

66.7

33.3

50

50

66.7

33.3

22

Making Choices, diversity & bioethics

50

50

33.3

66.7

33.3

66.7

23

Genetic Engineering & Food

16.7

83.3

66.7

33.3

33.3

66.7

24

Reproduction and Fertility

66.7

33.3

66.7

33.3

50

50

25

In Vitro Fertilization (IVF) Technology

0

100

66.7

33.3

50

50

26

Bioethics

66.7

33.3

83.3

16.7

66.7

33.3

27

Water Management

83.3

16.7

66.7

33.3

83.3

16.7

28

Assisted Reproductive Tech

83.3

16.7

100

0

83.3

16.7

No

TopicsHave you heard
about it?

Would you liketo study these
topics?

Yes

No

Yes

No

1

Artificial Insemination, Sperm, Egg & embryo
donation

96.3

03.7

92.62

07.4

2

Surrogacy

07.4

92.6

70.4

29.6

3

Somatic Cell Gene Therapy

55.6

44.4

85.2

29.6

4

Germ-line Gene Therapy

14.8

85.2

88.9

14.8

5

Human Cloning

85.2

14.8

85.2

14.8

6

Eugenics

18.5

81.5

70.4

29.6

7

SARS Severe Acute Resp. syndrome

100.0

00.0

88.9

11.1

8

Benefits Versus Risks

11.1

88.9

63.0

37.0

9

37.0

63.0

74.1

25.9

33.3

66.7

63.0

37.0

11

Animal Rights
Intrinsic and Extrinsic ethical factors overanimal use
Genetic Testing &Privacy

33.3

66.7

96.3

3.7

12

Testing for Cancer Gene susceptibility

22.2

77.8

85.2

14.8

13

AIDS Testing

51.9

48.1

92.6

7.4

14

The Heart Transplant

81.9

18.5

85.2

14.8

15

Ethics and Diving Cars

55.6

11.1

59.3

40.7

16

Ecotourism and Ethics

88.9

11.1

74.1

25.9

17

Sustainable Development

29.6

70.4

92.6

7.4

18

Euthanasia

25.9

74.1

77.8

22.2

19

Telling Truth about Terminal Cancer

44.4

55.6

96.3

3.7

20

Autonomy

81.5

18.5

85.2

14.8

10

Asia-Pacific Perspectives on Bioethics Education

Table India-3: Student preferences for topics at Pulicat National School, India (%)

91

21

Justice

92.6

7.4

100.0

00.0

22

Making Choices, diversity & bioethics

51.9

48.1

92.6

7.4

23

Genetic Engineering & Food

55.6

44.4

92.6

7.4

24

Reproduction and Fertility

81.5

18.5

81.5

18.5

25

In Vitro Fertilization (IVF) Technology

18.5

81.5

81.5

18.6

26

Bioethics

25.9

74.1

92.6

7.4

27

Water Management

88.9

11.1

81.5

18.5

28

Assisted Reproductive Tech

37.0

63.0

77.8

22.5

Results of teaching trials

92

Asia-Pacific Perspectives on Bioethics Education

Pulicat school is an example of a rural school. Three chapters were tested (Macer, 2004a): 16. Ecotourism
since the Pulicat Lake is a tourist place, 10. Genetically modified food, and 13. AIDS testing. In all of these,
the balancing of risks and benefits was explained. Copies of these chapters were given and written
answers were received which are being analysed.
The comments were written directly onto the bioethics page by page copies that were given out. The 27
students from the Pulicat trial had mixed religious backgrounds (Hindu 17; Muslim 4; Christian 6; Male
15 and Female 12), but it appears there was a similar diversity of views on bioethics issues that were
tested, consistent with the results of earlier studies (Macer, 1994). Regarding GM food many students
answered that they do not have access to a supermarket and that they grow natural foods themselves.
In these aspects it would be very interesting to develop intercultural communication between students
and teachers in the different “worlds” in which they live.
However the materials were interesting in this rural school and show that they can be used in different
cultures. The results to the questionnaire between Pulicat and Corley are quite different. Since thestudents attending Pulicat School hailed from a rural area it was suggested to them that they can use
Tamil, and this could be one factor.
Bioethics education is an area of immediate concern and students should be prepared to meet thechallenges of current scientific developments in both biosciences and medical sciences and theirapplications in human welfare. They should be equipped with necessary skills to deal with bioethicaldilemmas in resolving the philosophical and ethical issues involved in day to day life. Students are future
researchers and they should have the moral foundations to apply ethical standards and professional
codes of conduct. The appropriate means to do this must be found and used.

References
Macer, D.R.J., 1994. Bioethics for the People by the People Christchurch, N.Z.: Eubios Ethics Institute.
Macer, D.R.J., ed., 2004a. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios Ethics
Institute.
Macer, D.R.J., ed. 2004b. Challenges for Bioethics from Asia. Christchurch, N.Z.: Eubios Ethics Institute.

International approaches to evaluation ofbioethics education*
Darryl Macer, Ph.D.
UNESCO Bangkok,
ThailandCrucial to the development of bioethics education is a method of evaluation that allows for improvementof materials to better meet the needs of students in different countries. This paper looks at several
methods of evaluation including: development of specific evaluation forms for student and teacher
responses to chapters and the textbook or course; ways to analyze the content of student essays andreports; forums where educators and researchers can discuss and improve the content of the textbook
and materials, and discuss evaluation; and ways to assess various styles of student feedback fromdifferent programmes. These results are based on my experiences as a bioethics educator for two
decades, and the results of a project of bioethics education I coordinated under Eubios Ethics Instituteon “Bioethics Education for Informed Choices Across Cultures” (Macer, 2004a). This project was funded
by a grant from Sasagawa Peace Foundation, to compile and test open source teaching materials,
and these materials have been evaluated through numerous class trials as described in other papers
in this book, and papers presented at the Fifth Asian Bioethics Conference in 2004 in Tsukuba, Japan(Macer, 2004b). Some translations of the materials were made in several languages, including Chinese,
Japanese, Korean, Tamil and Thai, which allowed trials of bioethics education to be conducted in thelocal language in selected pilot countries.
Some Internet sites offer their own exclusive bioethics resources, but these are not always openly
available. One of the new sites on bioethics education that has not adopted an open access approachis the BioEthics Education Project (BEEP).1 BEEP is funded by the Welcome Trust and is based at theGraduate School of Education, University of Bristol, UK. The introduction reads well: “It is an interactive
website and virtual learning environment for secondary school science teachers and their students. It
is a teaching resource developed to highlight the moral, ethical, social, economic, environmental andtechnological implications and applications of biology.”
It also is aimed at web-based evaluation, “BEEP is also a research project; we aim to investigate whether
online discussion can be used successfully to support school science teachers. Thus use of the website
will be evaluated by researchers at the University of Bristol. Data on method of use and user opinion
will be collected and documents and presentations may be published concerning the project. However,end user contribution will be anonymised so that no individual or school will be identifiable in such
publications.” It provides a list of topics and ties these to several UK school curricula. The copyrightclause is restrictive however, stating: “Pages on BEEP are protected by copyright. No images, parts ofimages, or any other part of our website may be permanently copied or reproduced in any form or
reproduced on any other website or stored in or transmitted to or from any other electronic or digitalform in whole or in part without our prior written permission. In addition you may not alter, manipulate,
add to or delete an image or any part of an image. You may access and download the contents of thesepages and store a copy of them on a temporary basis for the sole purpose of viewing those pages.” Thus
for teachers to store, modify the pages to be suitable for their own local needs, use them, and place
the pages on their own websites would be breaking this copyright. Some distance learning courses
targeted to persons of particular value systems, such as the Jesuit Distance Education Network, Centre1

http://www.beep.ac.uk/content/index.php* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

Asia-Pacific Perspectives on Bioethics Education

Introduction93

for Online Bioethics Education2 are also found, but this project is aimed at cross-cultural materials for arange of value systems.

Goals of bioethics and evaluation
Although the expected achievements of each bioethics course differ with the educational goals chosen,
this paper discusses general principles of evaluation. There can be several goals of bioethics education,and each could be associated with different measures in evaluation. In the action plan for bioethics
education developed at the UNESCO Asia-Pacific Conference on Bioethics Education3 the goals aregrouped into knowledge, skills and personal moral development. There is no consensus in the academic
literature and teaching community on the most important goal to measure, nor on the best criteria toassess whether the education is successful.

94

Asia-Pacific Perspectives on Bioethics Education

For more than 60 years it has been recorded that both quantitative and qualitative data are importantin social science research, as was said by Merton and Kendall (1946), “Social scientists have come toabandon the spurious choice between qualitative and quantitative data: they are concerned rather withthe combination of both which makes use of the most valuable features of each. The problem becomes
one of the determining at which points they should adopt the one, and at which the other, approach”.
Thus an appropriate methodological tool should contain methods to utilize and assess both types ofdata.
The goals of bioethics that were important to measure as indicated by feedback from the project were
found to include: 1) Increasing respect for life; 2) Balancing benefits and risks of Science and Technology;3) Understanding better the diversity of views of different persons; 4) Understanding the breadth ofquestions that are posed by advanced science and technology; 5) Being able to integrate the use ofscientific facts and ethical principles and argumentation in discussing cases involving moral dilemmas;
6) Being able to take different viewpoints such as biocentric and ecocentric perspectives. We do notneed to achieve all goals to consider a class to be successful, and different teachers and schools put adifferent amount of emphasis on each goal.
One important goal of teaching about bioethical issues is to get students to critically evaluate the issues(Conner, 2003). In a Mexican case (Rodriguez, 2005), bioethics classes were used as a way to improve thegeneral behaviour and study aptitude of students. Each institution is likely to put a different amount ofemphasis on each goal. Also, different activities are likely to enable some goals to be met and not others(Macer, 2004c). Therefore we do not need to assess all the institutional objectives when evaluating the
success of the trials. Instead, case studies of how students and teachers responded were also sought togive a wider descriptive account of various approaches.
One of the goals of this project was to examine criteria that could be used to measure the success ofbioethics education, and the effectiveness of different forms of education for making mature citizens.
There is a consensus among many Western scholars that the balancing of four main bioethical principles,
which are Autonomy, Justice, Beneficence and non-maleficence, is central to making better decisions(Beauchamp and Childress, 1994). Autonomy includes ideas such as respect for privacy, respect for
personal choice.
Justice is to respect the autonomy of others, and to treat persons equally. Beneficence is to try to
do good, and non-maleficence is to avoid harm. When solving or trying to reach a consensus aboutbioethical problems, these four main principles can be a good guide in balancing which ideas should be
mostly weighed. One measure of bioethics education could then be whether students are able to use
these principles in decision-making, which was examined by presence of these keywords in discourse(oral or written). In the future the use of principles as expressed in the UNESCO Universal Declaration
on Bioethics and Human Rights (2005) will also be analyzed to broaden the description of bioethicalreasoning, and UNESCO is developing a core curriculum to teach bioethics based on inclusion of theconsensus view of bioethics as included in that Declaration.
23

http://www.ajcunet.edu/distanceeducation.aspx?bid=543
The action plan is included in this volume.

Still, reaching a good decision is often difficult, which also may not be the same if made in different
times and situations. Another approach that is common in education is to teach learners to break down
ethical dilemmas into manageable problems, for example, the separation of action, consequence andmotives connected to a moral decision. This separation is reflected on the different bioethical theories.
Utilitarianism is an example of a bioethical theory, which looks at the consequences of an action, and isbased on the work of Jeremy Bentham and John Stuart Mill. This principle asserts that we ought always
to produce the maximal balance of happiness or pleasure over pain, or good over harm, or positive value
over disvalue. Utilitarianism can be then broken down into rule utilitarianism, and act utilitarianism.

Integration of scientific facts is also important in moral reasoning. Science educators discovered during
the last few decades that the most efficient way to educate science is to discuss the science together with
examples of technology and put the facts into the social context. This method of teaching is generally
called the Science, Technology, and Society (STS) approach (Yager, 1990; Ramsey, 1993). Advancesin biology and medicine have led to another pressure upon educators, namely how students can beprepared to face the ethical dilemmas that the technology often raises. The ethical issues associatedwith biology are generally grouped under the phrase “bioethics”. Bioethics is one part of the approachof STS, and a survey of bioethics teaching is also one method to measure the extent that society issues
are included (Macer et al., 1996; Macer, 1999ab). In general there are less teachers using STS approaches
in Asia than in the USA (Kumano, 1991), and Australasia (Macer et al. 1996), but it is growing still. Even
within one country, such as the USA, there are a diversity of views on how to effect efficient educationof social issues and even the science itself (Waks and Barchi, 1992). In the project in Korea the partner
teachers at high school level are an STS network of teachers, and the Chinese school has a STS approachto teaching biology. In some other countries, such as New Zealand, STS approaches are integrated intoa broad participatory paradigm of education across all subjects.

Stages in moral development
In discussions held during this project there has been a consensus that the theory of moral development
developed by Lawrence Kohlberg, and what has come to be called Kohlberg’s stages of moral
development, does not universally apply when teaching bioethics. The problems are not only with nonWestern students, but researchers in Australia and New Zealand have also found that it does not serve
as a model. Kohlberg’s (1969) theory holds that moral reasoning, which he thought to be the basis for
ethical behaviour, has developmental stages that are universal. He followed the development of moral
judgment beyond the ages originally studied by Jean Piaget looking at moral development throughout
life, and created a model based on six identifiable stages of moral development (Scharf, 1978).
Kohlberg’s six stages were grouped into three levels: pre-conventional, conventional, and postconventional. He claimed it is not possible to regress backwards in stages nor to “jump” stages; eachstage provides new perspective and is considered “more comprehensive, differentiated, and integrated
than its predecessors.” A brief explanation follows.
Level 1: Pre-Conventional
The pre-conventional level of moral reasoning is especially common in children, and said to be up
to the age of nine in US children he studied, although adults can also exhibit this level of reasoning.
Reasoners in the pre-conventional level judge the morality of an action by its direct consequences.
The pre-conventional level consists of the first and second stages of moral development, and are
purely concerned with the self (egocentric). In stage one (obedience), individuals focus on the direct

Asia-Pacific Perspectives on Bioethics Education“A rule utilitarian may use moral rules as authoritative instrumental rules, so the morally right action is
conformity to a system of rules, and the criterion of the rightness of the rule is the production of as muchgeneral happiness as possible (Macer, 1998a)”. Act utilitarians on the other hand, look at the particular
act only, and object to moral rules to be only an approximate guides, which could be broken if maximal
good is not obtained. Another example of a bioethical theory is rights based theories of ImmanuelKant, and human rights law (Beauchamp and Childress, 1994; Macer, 1998a). The use of utilitarian-style
logic and rights arguments were also examined among the discourse. The evaluation tools developed
here could be extended to look for presence of other concepts such as virtue ethics for example.

95

consequences that their actions will have for themselves. For example, an action is perceived as morally
wrong if the person who commits it gets punished. In addition, there is no recognition that others’
points of view are any different from one’s own view.
Stage two is a self-interest orientation, right behaviour being defined by what is in one’s own bestinterest. Stage two reasoning shows a limited interest in the needs of others, but only to a point where
it might further one’s own interests, such as “you scratch my back, and I’ll scratch yours.” In stage two,concern for others is not based on loyalty or intrinsic respect. Lacking a perspective of society in the
pre-conventional level, this should not be confused with stage five (social contract) as all actions are
performed to serve one’s own needs or interests.

96

Asia-Pacific Perspectives on Bioethics Education

Level 2: Conventional
The conventional level of moral reasoning is typical of adolescents (age nine+ years) and adults.
Persons who reason in a conventional way judge the morality of actions by comparing these actions tosocietal views and expectations. The conventional level consists of the third and fourth stages of moral
development. In Stage three, the self enters society by filling social roles. Individuals are receptive of
approval or disapproval from other people as it reflects society’s accordance with the perceived role.
They try to be a good boy or good girl to live up to these expectations, having learned that there isinherent value in doing so. Stage three reasoning may judge the morality of an action by evaluating
its consequences in terms of a person’s relationships, which now begin to include things like respect,gratitude and the golden rule. Desire to maintain rules and authority exists only to further support thesestereotypical social roles.
In Stage four, it is important to obey laws and social conventions because of their importance inmaintaining a functioning society. Moral reasoning in stage four is thus beyond the need for approval
exhibited in stage three, because the individual believes that society must transcend individual needs. If
one person violates a law, perhaps everyone would - thus there is an obligation and a duty to uphold laws
and rules. As a cultural observation, this is a very common attitude in Asian and Pacific communities.
Level 3: Post-Conventional
The post-conventional level, also known as the principled level, consists of stages five and six of moral
development. Realisation that individuals are separate entities from society is important in North
American society where Kohlberg developed his theory and so he judged it to be a higher level of morality.
In that culture one’s own perspective should be viewed before the society’s is considered. Interestingly,
the post-conventional level, especially stage six, is sometimes mistaken for pre-conventional behaviour.
In Stage five, individuals are viewed as holding different opinions and values, all of which should be
respected and honoured in order to be impartial. However he considered some issues are not relative
like life and choice. Laws are regarded as social contracts rather than dictums, and those that do notpromote general social welfare should be changed when necessary to meet the greatest good for thegreatest number of people (a utilitarian view).
In Stage six, moral reasoning is based on abstract reasoning using universal ethical principles. Decisions
are made in an absolute way rather than in a conditional way. In addition, laws are valid only insofar as
they are grounded in justice and that a commitment to justice carries with it an obligation to disobey
unjust laws. While Kohlberg insisted that stage six exists, he had difficulty finding participants who use
it.

Implications
After Kohlberg’s stage four, the transition from stage four to stage five, people have become disaffectedwith the arbitrary nature of law and order reasoning and he said they become moral relativists. Thistransition stage may result in either progress to stage five or in regression to stage four. As has become
clear during the bioethics education project, there is such a range of cultural, family and school value
systems across the world, that students of one age in one country will most likely be in different stages
at different times, even if all persons did follow this progression from stage one to stage six in moral

reasoning, and not revert back to other levels. Stage six would correspond to a person that followed the
textbook bioethics of Beauchamp and Childress (1995). Macer (1998) has argued that bioethics is loveof life, and that principalism based on following the standard ethical principles alone is not sufficientas an explanation of why people behave the way they do. The role of religious values is also obviously
important, as concepts like karma and removal of oneself from the matters of the world do affect thevalues systems people use when approaching moral dilemmas.
Kohlberg used moral dilemmas to determine which stage of moral reasoning a person uses. The
dilemmas are short stories that describe situations in which a person has to make a moral decision,
yet they provide no solution. The participant is asked what the right course of action is, as well as an
explanation why. This style is still commonly used as case-based ethics teaching. There is a need todevelop more local cases for dialogues between Asian and Pacific cultures.

Heinz Steals the Drug In Europe: A woman was close to death from a special kind of cancer. There
was one drug that the doctors thought might save her. It was a form of radium that a druggist in thesame town had recently discovered. The drug was expensive to make, but the druggist was charging
ten times what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for asmall dose of the drug. The sick woman’s husband, Heinz, went to everyone he knew to borrow themoney, but he could only get together about $1,000 which is half of what it cost. He told the druggist
that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: “No, I
discovered the drug and I’m going to make money from it.” So Heinz got desperate and broke into theman’s store to steal the drug for his wife (Kohlberg, 1969).
Should Heinz break into the laboratory to steal the drug for his wife? Why or why not?
Like many cases of bioethics, from a theoretical point of view, it is not important what the participant
thinks that Heinz should do. The point of interest is the justification that the participant offers. Below are
examples of possible arguments that belong to the six stages. It is important to keep in mind that thesearguments are only examples. It is possible that a participant reaches a completely different conclusion
using the same stage of reasoning:
Stage one (obedience): Heinz should not steal the medicine, because he will consequently be putin prison.
Stage two (self-interest): Heinz should steal the medicine, because he will be much happier if hesaves his wife, even if he will have to serve a prison sentence.
Stage three (conformity): Heinz should steal the medicine, because his wife expects it.
Stage four (law-and-order): Heinz should not steal the medicine, because the law prohibits
stealing.
Stage five (human rights): Heinz should steal the medicine, because everyone has a right to live,
regardless of the law. Or: Heinz should not steal the medicine, because the scientist has a rightto fair compensation.
Stage six (universal human ethics): Heinz should steal the medicine, because saving a human life
is a more fundamental value than the property rights of another person. Or: Heinz should notsteal the medicine, because that violates the golden rule of honesty and respect.

One criticism of Kohlberg’s theory is that it emphasizes justice to the exclusion of other values.
As a consequence of this, it may not adequately address the arguments of people who value othermoral aspects of actions more highly. His theory was the result of empirical research using only maleparticipants (aged 10, 13, and 16 in Chicago in the 1960s). Carol Gilligan argued that Kohlberg’s theory
therefore did not adequately describe the concerns of women. She developed an alternative theoryof moral reasoning that is based on the value of care. Among studies of ethics there is a tendency

Asia-Pacific Perspectives on Bioethics Education

A dilemma that Kohlberg used in his original research was the druggist’s dilemma:97

in some studies to find females have higher regard for ethics theories (Ford and Richardson, 1994).
Gilligan’s theory illustrates that theories on moral development do not need to focus on the value ofjustice. Other psychologists have challenged the assumption that moral action is primarily reached byformal reasoning. People often make moral judgments without weighing concerns such as fairness, law,human rights and abstract ethical values. If this is true, the arguments that Kohlberg and other rationalist
psychologists have analyzed are often no more than post hoc rationalizations of intuitive decisions. This
would mean that moral reasoning is less relevant to moral action than it seems (Crain, 1985).

Integrating evaluation methodologies with goals of bioethics
education
In current assessment of students there is a trend from merely making lists of many examples, or listing
the positive and negative sides of an argument towards making students exhibit their reasoning as well.
One of the common goals of school education is that students can produce a good argument. Stephen
Toulmin’s model has become popular in development of students’ argumentation skills (Toulmin et al.
1984). An argument consists of integrating the following:
A conclusion or claim – assertions or conclusions about an event or theory
Facts – data that is used as evidence to support the assertion98

Asia-Pacific Perspectives on Bioethics Education

Warrants – the statement that explains the link between the data and the claims
Backing – underlying assumptions which are often not made explicit
Rebuttals – statements that contradict the data, warrant or backing of an argument
To create an argument a person needs to state their claim, then support it with facts (data) that arearranged logically. For each fact, they should give the evidence for the fact (warrant), and for eachwarrant, state the quality of its validity (backing). Then for each warrant and its backing, people should
think of an opposing point of view (rebuttal). They then consider further possible warrants and backing
for the rebuttals. At the end then they review, having argued the rebuttals, do they need to qualify their
original claim?
The mental mapping project, or human behaviourome project (Macer, 1992) identified nine classesof ideas, and attempts to explain the linkages between ideas in the construction of moral choices bydifferent persons (Macer, 2002a). The practical applications of that model are yet to reach a stage at
which teachers could simply assess the moral development of their students. The Ideas, Evidence andArgument in Science Education (IDEAS) project of Osborne et al. in the UK4, has as its goal the assistanceof teachers in developing their skills to teach about ideas, evidence and argument in science. The
materials they wish to develop include worksheets and video clips to enable teachers to teach children
to develop and evidence scientific argument. The IDEAS project suggests the following criteria can beused in evaluating students’ arguments: Is there a claim? Does the argument have data to support theclaim? Does the argument link the data to the claim? Are there further justifications to support the case?
Is there any anticipation of a counter argument and how it could be opposed?
Ratcliffe and Grace (2003) outline the knowledge, understanding and skills that students studying
ethical issues in science acquire and that can be used to design assessment questions. They listed
several different levels of knowledge:
Conceptual knowledge: Learners can demonstrate understanding of: underpinning science
concepts and the nature of scientific endeavour; probability and risk; the scope of the issue –personal, local, national, global, political and societal context; and environmental sustainability.
Procedural knowledge: Learners can engage successfully in: processes of opinion forming/
decision making using a partial and possibly biased information base; cost-benefit analysis;
4

http://www.kcl.ac.uk/depsta/education/ideas.html

evidence evaluation including media reporting; and ethical reasoning.
Attitudes and beliefs: Learners can: clarify personal and societal values and ideas of responsibility;
and recognize how values and beliefs are brought to bear, alongside other factors, in consideringsocio-scientific issues.
As with the above examples of questions that Kohlberg used for the linkage of student arguments to
moral stages of development, there are a number of ways that could be developed into evaluation tools
for assessment of bioethics education.

Evaluation must be done ethically (Alderson and Morrow, 2003), and there are a variety of methods inresearch which can be applied for evaluation depending on the style of class and purpose (Cohen et al.,2003). It is very important to examine the future direction of bioethics education and how this mightenable people to question scientific endeavours and what impact their moral decisions will have onthem as individuals and upon their societies. The skills that are required to do this involve the ability toidentify existing ideas and beliefs, listen to others, be aware of multiple perspectives, find out relevant
information and communicate the findings to others. These skills cannot be “given” to students througha didactic approach to teaching, where the teacher imparts the knowledge. Instead, students need toexperience situations that will allow them to develop these skills through interacting with the teacher
and with each other. This project allows sharing of cases and experience in a range of cultures as well.
When bioethics is applied to professional behaviour, such as in medical ethics, methods to evaluate haveincluded the way students conduct a patient examination. In Buffalo University Bioethics programme5(Singer et al., 1993), they applied the technology of the objective structured clinical examination (OSCE)(Cohen et al., 1991) using standardized patients to the evaluation of bioethics. Methods to evaluate
the clinical-ethical abilities of medical students, post-graduate trainees, and practising physicians thathave been used include multiple-choice and true/false questions (Howe and Jones, 1984), case writeups (Siegler et al, 1982; Doyal et al., 1987; Redmon, 1989; Hebert et al., 1990), audio-taped interviews
with standardized patients (Miles et al., 1990), and instruments based on Kohlberg’s cognitive moral
development theory (Self et al., 1989).
The reliability and validity of these methods have seldom been examined. Auvinen et al. (2004) applied
the use of Kohlberg’s stages of moral development to assess ethics teaching in nursing students in
Finland, and they found significantly higher ethical maturity when nurses actually had to deal withethical dilemmas in their practical training in clinics.

Evaluation Instruments
Previous papers in this volume and in Macer (2004) have presented much of the general results of the
project. An attempt at a centralized instrument for recording feedback was made, so that after pilot
trials the set of evaluation sheets that appear in the initial pages of A Cross-Cultural Introduction to
Bioethics (Macer, 2006; pp. vii-xvii), were developed. There was a balance in the development of specific5

http://wings.buffalo.edu/faculty/research/bioethics/eval.html

Asia-Pacific Perspectives on Bioethics Education

One of the difficult questions in bioethics education is how to evaluate the usefulness of the materials
provided, beyond mere student or teacher satisfaction. One concept that has been used by Macer iswhether students demonstrate “bioethical maturity” in some way. “Bioethical maturity assumes a certain
level of recognition of weighing up the different arguments that can be used to discuss an issue, thedifferent ethical frameworks that can be used, and comparisons and balancing of the benefits and risksof the dilemmas (Macer, 2002a). This process also gives an indication as to how many different ideas
people have, and the way they understand the dilemmas, and is ongoing as part of the behaviourome
project (Macer, 2002a; 2004b). Classroom observations, audio and video tape recordings, and written
essays and homework done by the students were collected. This feedback is being continually used tomodify the texts and accompanying questions and materials for teachers. Another way to assess theusefulness of the materials for developing ethical principles in making ethical decisions was to look for
key words and concepts in the answers students give to oral questions.

99

evaluation forms for student and teacher responses to chapters and the textbook or course between
examination of the way that the thinking progressed and the privacy of the respondents. A comparisonof the questions in the form with the goals of bioethics is presented in Table 1.
Table 1: Examination of indicators that correspond to the goals of bioethics in instruments
Teacher Chapter
QuestionsIndirectlyStudent Chapter
QuestionsIndirectly

Report Coding
Categories
Overall conclusions2) Balancing benefits
and risks of Scienceand Technology

Indirectly

Indirectly

Both Sides of View

3) Understanding
better the diversityof views of different
persons

Q7 The chapter was
helpful in provoking
meaningful
discussion in theclass; Q12. Was
there any content
and/or questions
that are notappropriate for yourcultural values andnorms?

Q5. The chapter was
helpful in provoking
meaningful discussion
in the class. Q10. Were
there any contents and/or questions that are
not appropriate for yourcultural values andnorms? Q15. The ethicalconcepts were learned
through a series of
discussions more than theteacher’s lecture.

Personal opinion versus
OthersBoth Sides of View

4) Understanding thebreadth of questions
that are posed byadvanced science andtechnology

Q2. What key words
were repeatedthroughout thediscussion among
the students?

Q2. What key words wererepeated throughout thediscussion?

Number of Ideas
Both Sides of View
Utilitarian Views
Environmental/
Biocentric Views

5) Being able tointegrate the use ofscientific facts andethical principles
and argumentationin discussing cases
involving moral
dilemmas

Q9. The questionsin the chapter are
helpful to guidemeaningful thinking
and further study/
research on the
topic.

Q7. The questions in
the chapter are helpful
to guide meaningful
thinking and further
study/research on the
topic. Q13. The teacher
welcomed questions/comments.

Scientific Facts
Quantitative Facts
Principles & Keywords
RightsUtilitarian Views

6) Being able to takedifferent viewpoints
such as biocentricand ecocentric
perspectives.

Indirectly

Indirectly

Environmental/
Biocentric Views

Goals

100

Asia-Pacific Perspectives on Bioethics Education

1) Increasing respect
for life

The raw data was input into Excel tables for analysis as it included both multiple choice question
responses and text strings. The results show that the students were very positive to the materials andtopics. Significant numbers wanted to have longer to discuss the materials and topics, though in thesetrials the class times varied. The results show that the students were very positive to the materials andtopics. Significant numbers wanted to have longer to discuss the materials and topics, though in thesetrials the class times varied from 50 to 120 minutes. In all classes I gave as pilots (mainly in India, Japanand Thailand) the students felt that they had enjoyed a meaningful discussion. The teachers were

unanimous in judging the materials to be adequate, and strongly agreeing with the utility of chapters.
They also wanted more time for the discussion.
The comments given in the response forms were the most useful parts of the form for the whole rangeof age groups. One open question (Q2) asked students to list keywords, and the students usually wrote
three keywords about each chapter, often the title plus a principle that was emphasized during thelecture. The open comments that looked at what the students wrote as having learned through reading
the chapter usually elicited a sentence or two. The answers were coded. More often younger students
listed more facts in response to this question than older ones, with increasing proportions of students
mentioning ethical principles in their comments in the older medical students. Only 12-24% of Indian
students gave a comment that illustrated they had learned about both sides of view. If the questionnaire
directly asked whether they had learned about different points of view more said so, but still most
students focused on the facts or keywords of the chapter in their comments.

Overall, 25 students of 107 (23%) thought that the lecture included materials difficult for their culture,in particular surrogacy. Given the widespread moral condemnation of surrogacy around the world it
may be a similar response in other cultures. What is interesting is that in the city, Chennai, there areseveral surrogacy clinics operating commercially. It would be quite interesting to arrange lectures by
the clinicians with students and see their reaction to practical cases, and this was done for Universityof Madras students in January 2006, with much interest shown by the students. The chapter does notsupport surrogacy or condemn it, taking a neutral view, thus we would expect a greater disagreement
if the materials promoted only one side of an argument.

Evaluation and networking
Forums where educators and researchers can discuss and improve the content of the textbook andmaterials, and discuss evaluation methodology were held in several countries in order to examine
the types of meetings that can provide useful feedback in material development. These proved to beimportant because they seem to be better opportunities to obtain detailed feedback by the educatorsand researchers conducting bioethics education than using forms or reports.
The largest and most international of these meetings was held in September 2005 in Bangkok during
the First UNESCO Bangkok Bioethics Roundtable. During that meeting the question of evaluation was
discussed. If bioethics becomes compulsory, should it have an exam? If yes, then should there be aquestion book? Will an exercise book be produced? Despite a common idea that exists on the groundin many Asian countries, to teach ethics with evaluation via multiple choice questions is opposed tothe spirit of this project. Evaluation can still be done by writing essays, reports and oral interviews. Text
analysis of the reports for keywords was undertaken, extending categorisation methods that have beendeveloped (Maekawa and Macer, 2005), and the results are described in an accompanying paper (Macer
et al., 2008). However, the real results are in the value systems and decision making processes that are
established in the students.
The common evaluation methods described included client participation, tests, essays, reports
and surveys. Lindsey Connor described the situation in schools in New Zealand. They have a lot ofenvironmental programmes. There are two systems for evaluation, one informal and one formal system.
The informal system includes discussions, teacher questionnaires, and students working together anddesigning their own questionnaires, designing interviews they might do in the community. Sometimes
they develop pamphlets and posters. It is not part of an exam though. In the formal system, there might

Asia-Pacific Perspectives on Bioethics Education

One of the concerns in developing cross-cultural materials is whether some contents are not appropriate
in a culture. This concern was also raised in Catholic schools that used the first edition of the textbook,though they judged all the contents to be appropriate. The results show that most students and teachers
believed that the materials were appropriate, though some further specific materials to issues arising intheir local environment and society were called for. One example is the topic of assisted reproductive
technology, which was given in a lecture at a girl’s senior high school in India, with the approval of theprincipal and teachers, because it was something considered difficult to teach. The issue of reproduction
also was relevant to teenage girls.

101

be questions and a test or they may be assessed formally through assignment work. Sixteen to 17 and18 year old senior biology students are assessed by essays. There is a shift from central examinations
to the assessment being done by the teacher. Some are moderator checked at other levels by external
examiners. There are no marks out of 100. It’s all about what students have shown that they can do. The
assessment is very different, it is graded on what they can do. They can achieve merit or distinction,
there are no numbers involved.

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Asia-Pacific Perspectives on Bioethics Education

The standards are very clearly described in curriculum documents, there are four broad levels so theteachers have examples of what a merit or excellence might include. There are examples of those
assessments on a national level with science so that both students and teachers can go and see examplesof what levels of criteria might be. This aspect is new in New Zealand; it just came in 2004. When asked
what might be defined as “underachieved”, Connor answered that it depends on the standards, there
are 24 credits for each subject. So each standard, depending on the subject is divided up differently.
Some standards are worth three credits, some are worth five credits. Some standards target practicalwork, some standards targets target recall of knowledge and some standards target bioethics etc. It’svery different depending on the standard. Teachers and students can go to the website for references.
For tertiary level, New Zealand has both informal and formal assessment methods at university. Informal
assessment is about participation and the contribution to group work, which is not documented but
assessed by the educator at the time. Formal assessment is still by essay.
Michael Anjello Jothi Rajan from rural India said when the first text book on bioethics education was
introduced, it was handled by management as the textbook for values education. In the class of 650
students the evaluation was done by questionnaires including both open-ended and closed-ended
questions.
Qui Renzong from China noted there is an important issue of how to evaluate the bioethics teaching.
In his opinion, there are two aspects of the evaluation. One, how much knowledge do they learn afterclass or in the course? Second, have they learnt and what is their capacity for ethical argumentation?
What is their capacity for solving ethical issues in practice? The first part is easy, but also they are justlike the written method of exam assessment. But how do you know the students haven’t just taken theanswers from the textbook? Around 300 students attended his class on bioethics. Later, he asked themto analyse. After class, we provided the same questions so that we can compare what they have learnedat the end of the class to what they knew at the beginning of the class. There are many aspects of varied
education. Most of them use written works. They use the case-studies. The ethical argument is secondusing the written paper. How do you know if they are using the ethical arguments? Xiaomei Zhai notedthat the syllabus is totally different.
We have to focus on capacity building. We have a different goal, a different method, a different
assessment. For medical students, the first part is after university after they have finished the very basic
phase of general knowledge. During the second stage, after they have practiced at hospital then we
focus on case-studies for the assessment, etc. Usually we just focus on those practical issues. What is the
purpose for you attending these courses? Then we can modify and revise our course. After the courses
we have another questionnaire about that.
For training of ethics review committee members, they can be given a mock review, for example.
Xiaomei Zhai from China noted that in almost every course for IRB members, we have at least two groupexercises and one is a mock ethics review. And then all the participants are able to analyse it. During themock review usually there is a very hot debate on this. All the participants have to call upon their ability.
Yanguang Wang said that when she teaches post-graduate training, some physician doctors learn
bioethics. Even if they did not have bioethics courses, they can ask: “Try to find out what is a bioethicalquestion?” They get the students to work in hospitals and submit this survey form. The question is to ask
whether the student really knows what and how to deal with this.
Daphne Furtado from India said that there was no formal assessment but at the end of the last year justbefore medical students become interns, they are supposed to write a paper. It can be on any subject.
Then they compete for an ethics prize. Very often it is someone who has more capacity for language orsomeone who has read more, rather than capacity building for ethical practices.

Teachers from Affiliated High School to Beijing Normal University said that China is one of the first
countries to consider the trials and they have two evaluation systems in the country. Classes in the
middle school attached to Beijing Normal University, Xuanwu District, in Beijing, required students towrite three articles, either in English or in Chinese. Grades are based on their participation in the lectures
and the quality of writing. The teachers analyzed their results and improved the performance. There isa second evaluation system of the course, mainly done by questionnaires and surveys.

A growing number of people, involved in trials and meetings, eventually developed into the International
Bioethics Education Network, which was first founded in Tsukuba in 2004. This network has since met
every year as one subgroup within the UNESCO Asia-Pacific School of Ethics. The emerging International
Bioethics Education Network was adopted as part of the ethics network from UNESCO Bangkok as the
UN started to pay more attention to the regional needs for bioethics education.
As the project expands to more countries and more classes, the budgetary constraints will need to be
overcome. The fundamental extent of the project will depend on those factors, and gathering teacher
enthusiasm, which was generated through three years of funding under SPF.

Conclusions
This international and cross-cultural project has expanded our understanding of the range of goals of
bioethics. We do not need to achieve all goals to consider a class to be successful, and different teachersand schools put a different amount of emphasis on each goal. What is important at all these levels is how
to evaluate whether our teaching is having any impact or not. Because investigating bioethical issues iscomplex, the educators need to consider what knowledge needs to be developed in order for students
to make sense of moral issues, to be able to critically evaluate them and to possibly take action basedon this knowledge. Knowledge in this sense includes: Knowledge of the science/technology content;
knowledge of reflective processes (individual views); exploration of morals/values (values clarification);knowledge about bias and how to detect it (values analysis); knowledge about political agendas, forexample (Conner, 2005). Sadler and Zeidler (2005) showed that tertiary students frequently rely on
combinations of rationalistic, emotive and intuitive knowledge as they worked to resolve scenarios
about genetic engineering. Persons at all levels do mix ideas in different ways (Macer, 1999b; 2002a)
and this was shown in the evaluation report that is an output of this project.
Evaluation reports (completed student and teacher feedback forms, and also student reports) continue
to be gathered to revise the materials in an ongoing process. The evaluation tool included in the
textbook is workable and has gained useful comments from students and teachers, however mostteachers are too busy to fill in any evaluation form unless some extra incentive is given. There is still aneed for analysis of reports and discourse in order to gain a greater impression of how student values
changed, and a suggested coding frame is made. It can be extended case-by-case to add new keywords
and concepts which are important for the specific research goals of the evaluation, as well as topicspecific goals.

6

Bioethicseducation@yahoogroups.com

Asia-Pacific Perspectives on Bioethics Education

To extend these meetings there were also comments circulated on the yahoo group’s “listserve”6,
which will continue as a method to circulate news on the project. Although the chapters were tested
in several different countries, there was little correspondence through the yahoo group’s <Bioethics_
for_students@yahoogroups.com> and <Bioethicseducation@yahoogroups.com>. There was direct
correspondence between some teachers, but the bulk of discourse occurred during special events held
to discuss the project. There was also a value in smaller meetings of about a dozen experts that canbring together comments focused on particular themes in free discussion. National-level meetings that
focus on correlation to particular national systems of evaluation can also be very useful in mapping
linkages for formal assessment criteria that can be integrated into the examination systems that eachcountry, or school system, uses. Because investigating bioethical issues is complex, the educators needto consider what knowledge needs to be developed in order for students to make sense of moral issues,
to be able to critically evaluate them and to possibly take action based on this knowledge.

103

Pre and post questionnaire surveys about specific topics relating to the content of the lecture or teachingintervention (Maekawa and Macer, 2004) can be useful to measure change, however, in my opinion,
report and discourse analysis provided a more reliable judgment because the object is to see the use of
ethical principles and moral reasoning all the time. The object is not to just write tests for students.
There are several different ways to assess learning in bioethics. Different teachers have overlapping
priorities and these are consistent with the results of surveys of teachers a decade ago (Macer et al., 1996).
There needs to be assessment methods to map these different goals, including: how to demonstrateincreased respect for life; how to balance benefits and risks of scientific technology; how to balancedifferent perspectives, scientific data and ethical values; to get students to acknowledge individual,
cultural and political influences over societal policy making, as well as upon their own moral choices.

104

Asia-Pacific Perspectives on Bioethics Education

A mix of qualitative and quantitative methodology can help in the monitoring of bioethical maturity,
but there is more to gain from qualitative discourse analysis. Pre and post questionnaire surveys about
specific topics relating to the content of the lecture or teaching intervention (Maekawa and Macer,2004) can be useful to measure change, however, in my opinion, report and discourse analysis provide
a more reliable judgment because the object is to see the use of ethical principles and moral reasoning
all the time.
The project exposed many teachers and students to the concepts and practice of bioethics education.
The increased motivation in a number of teachers to develop their own materials and class strategies
for teaching bioethics is the grounds upon which future expansion can be expected. The expansionof the topics and themes in the second compiled resource book (Macer, 2006) called A Cross-Cultural
Introduction to Bioethics, was the result of an ongoing evaluation process that educators wished formore broad coverage and access to materials beyond high technology issues.
This was an outcome of the First UNESCO Bangkok Bioethics Roundtable. A discussion from that meetingis also available (Macer, 2005). In this sense the project helped expand the boundaries of bioethics
internationally. That book and some translations of materials in the book in several languages, including
Bahasi Indonesian, Chinese, Japanese, Khmer, Korean, Spanish, Tamil, Thai, Urdu, and Vietnamese areavailable through the website. An on-line living bioethics dictionary is also a useful resource (Macer,
2002b). Materials to teach bioethics are becoming more accessible as more languages and subjects areadded, and these are being widely distributed with the textbook. The teachers resources and notes on
the web are being developed further, along with internet links which allow students who wish to write
projects on these themes to extend their knowledge (such as postgraduate students in countries wherereports form an integral part of the assessment). Improvements were made to the UNESCO/IUBS/Eubios
Bioethics Dictionary (Macer, 2002b), which is on-line to extend and cross-link definitions, as anotherresource which teachers can download and use (in MS Word and html formats).
There have been other books produced as teaching resources which provide materials for teachers andstudents, e.g. Levinson and Reiss (2003), but they cannot be accessed for free, making these resourcesdifficult to use in developing countries. One of the positive points expressed over this project’s text/
resource book was that the science is also up-to-date, compared to textbooks used for teaching sciencein even a rich private school in the Philippines, which were ten years out of date. One of the key objectives
is to provide up-to-date information breaking down the information divide so that the facts used in theconstruction of moral arguments are current scientific knowledge. This is also attractive to learners.
Approaches are also now being made at the policy level through UNESCO to help complement thegrass roots initiative in this project to produce materials. The position of UNESCO Bangkok, as theRegional Bureau for Education in the Asia-Pacific Region, with access to curriculum policy makers at the
governmental level, means that the project can continue with input from the top level down.
In addition, access to experts in the development of education will aid the necessary process ofadaptation of materials that have been gathered to the specific needs of each curriculum. The approach
will not attempt to interfere with the syllabuses and curricula decided by educational authorities, but
the intention is that the materials will augment existing curriculum delivery. In a number of countries,
the curriculum documents state the general goals of educating students to better face the ethical andsocial issues relating to the use of science and technology, but lack practical measures to implement

these ideals. As part of the increased attention given to bioethics education, we can expect to also see
other resources being placed on the Internet for teaching about these issues. There is a need for more
freely available resources to be placed on the Internet in multiple languages, suitable for a range oflevels, school systems (and informal education) and countries. At some stage in the future it may be
useful to have some symbol of accuracy and neutrality of the information, because there is already arange of materials on the Internet that are presenting a distorted view of information.
Teachers from all countries continue to express a need for supplementary teaching materials, andthese are being deposited online for free download. Depending on the country these include overheadtransparencies, PowerPoint files, DVDs or video tapes, drama scripts and museum displays. In additional
movie guides for teaching bioethics from movies are being added to the online resources.

There are several different ways to assess learning in bioethics. There needs to be assessment methods
to map these different goals, including: how to demonstrate increased respect for life; how to balance
benefits and risks of scientific technology; how to balance different perspectives, scientific data andethical values; to get students to acknowledge individual, cultural and political influences over societal
policy making, as well as upon their own moral choices. A mix of qualitative and quantitative methodology
can help in the monitoring of bioethical maturity, but there is more to gain from qualitative discourse
analysis.

Acknowledgments
I would like to thank the Sasakawa Peace Foundation (SPF) for their essential financial support in theform of a grant to the Eubios Ethics Institute. Special thanks to: Catherine van Zeeland, Naoko Kimura,Philippe Gruson, Sarinya Sophia, Nobuko Macer, Mihaela Serbulea, MaryAnn Chen Ng, Dena Hsin-Chen
Hsin, Irina Pollard, Lindsey N. Conner, Alireza Bagheri, Morgan Pollard, Minakshi Bhardwaj, Jayapaul
Azariah, Jothi Rajan, Arockiam Thaddeus, Senthil Kumaran, Ivo Kwon, Eun-young Kim, Rick Weisburd,
Margaret Sleebom, Anoja Fernando and Daphne Furtado. In China I thank Jing Zhuo, Li Kuang, Jinhua
Fu, Lei Li, Yongmei Gu Jianzhi Li, Bin Wang and Yuan Yu; in India Mrs. Ahalya William, Mrs James, A.
Nalini, M. Selvanaygaam, Aruna Sivakami; and in the Philippines we thank Milarosa Librea-Gajo, Carmela
C. Oracion, Ester Abito, Alma Pavia, Margarita Pavia, Manny Perez, Bella Queao, Libertine Sanchez,
Suzanne Zambrano. I thank Tetsuya Ishizuka and Norio Ohto from SPF for useful comments. We thankmany other colleagues in these and other countries, and the students around the world. The website of thebook and teaching resources is http://www.unescobkk.org/index.php?id=2508

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Content analysis of bioethics reports*
Darryl Macer, Catherine van
Zeeland, Naoko Kimura andPhilippe Gruson,
UNESCO Bangkok, Thailand

Introduction

For analysis of both “personal moral development” and making time trend analysis through “thematiccomparisons over time”, summary data tables are presented below to visualise the trends and ideas ofeach selected report. The analysis used the following evaluation criteria in order to analyse each reportfrom different perspectives. The abbreviations used for the coding categories are below:
Both Sides of View (BV): More than one side of an argument or a question being mentioned. Sometimes
the views were not clearly stated in individual sentences so the judgment of the report containing a BV
or not had to be made after the full evaluation of the report.
Personal vs. Other Persons’ Views (PO): The writer’s point of view (e.g., an “I think” statement) plus
other people’s point of views being stated regardless of whether they concurred with those of the writer
or not. Views/feelings of non-humans were not included in this category.
Scientific Facts (SF): A concrete and/or detailed scientific fact more intellectually demanding thancommon sense or the broad theme of the report. Generally this was not merely the citation of sentencesfrom reference material(s).
Quantitative Facts (QF): The use of statistics and/or numbers in a factual manner.
Environment and Biocentric Ideas (EB): A statement made mentioning concerns for the environment
or ecological concerns, or for example the care or treatment of animals raised as a concern. Generally
people tend to reason and write from an anthropocentric viewpoint.
Utilitarian Views (UV): A utilitarian view is judging an act as being morally acceptable based on theopinion that the benefits of the action to one group or individual will outweigh the risks or harm
produced affecting a larger population. It also considers the balance of society versus individuals.
Principles and Keywords (PK): A keyword denoting an ethical principle or connotation of one regardlessof whether being directly stated or not. If only the term “rights” was mentioned, it was marked as “R”
and not “PK”. Keywords included specific bioethics principles and keywords such as benefit and risk
assessment, informed consent, enhancement, public welfare, autonomy, justice, equality of life, animal
welfare etc.
Rights (R): Clear mention of a right or a connotation of a right. This was limited to the rights of humanbeings. “R” is a specialised category of “PK”.
Number of Ideas (NI): An idea is a distinct message unit, statement or concept that may be from thematerials or from the writer’s own thinking. Key words and concepts were numbered when going
through the reports and the same idea when repeated was not scored twice.

*

Paper first presented at the UNESCO Asia-Pacific Conference on Bioethics Education, held 26-28 July 2006 in Seoul,
Republic of Korea.

Asia-Pacific Perspectives on Bioethics Education

This paper presents the results of text analysis of reports about bioethics topics using keywords. The
research was undertaken to examine the results of the “Bioethics Education for Informed Citizens AcrossCultures Project” (Macer, 2004a), extending categorisation methods that have been developed to lookat the content of discourse (e.g. Maekawa, 2002; Maekawa and Macer, 2005).

109

Main Idea (MI): The selection of a main idea was based on the main themes of the argument. It is related
to the causal relationship between two or more ideas. Often the sentence answering the topic question
was chosen as the main idea.
Example comments below give some explanation of the coding:“Animals are life as we are. I think all life should be allowed to live. So I think that they have aright to live.”(R)“I thought my knowing was worth dissecting without consciousness.” (UV)
“We have legal rights (R) which shield us from unjust things. Instead of it, we have to fulfil
duties.”(PK)“I don’t agree to give animals legal rights. (R) But I think that we should not kill animals uselessly(BV) and it is important we protect the environment.” (EB)“All cells of transgenic animals have injected genes. Injected genes can be expressed in specifictissues with proper promoters.” (SF)110

Asia-Pacific Perspectives on Bioethics Education“I do not want to use animal tests for the safety of cosmetics, but some other people think that itis better to have everything tested on animals.” (PO)The first quotation mentions rights, which can vary in other reports such as the right to choose, rightto information, and the right to death, just to mention a few. The second quotation mentions utilitarianviews. Other utilitarian views include comments such as “If it can cure many people, animal experiments
are inevitable” or “For the progress of science there are always some sacrifice.” The third quotation is an
example of a specific bioethics principle and keyword, “duty”. The next example shows both sides ofview where this person disagrees to give legal rights to animals, but considers unnecessary killing. Also
the importance of environmental protection is mentioned for animals to be able to live in their natural
habitat, which is a rare case. The next example shows some scientific background, SF. The last example
takes the position of the animal that is being experimented. Other possible position may be that of thescientist, or of persons deeply against animal testing, but the key point is comparing their own opinion
with others. In order to verify coding, the reports were discussed among three primary coders with theauthor checking the codes of the tables.
The above codes were written at the appropriate places in the report upon reading and then tallied.
The raw data that was used to validate the coding system were reports in English made by students
attending classes of Darryl Macer at the University of Tsukuba, Japan. This standardises for the range ofstudents, culture and teacher, which are all potential variables on the type of reports that were given.
Such factors need to be taken into account when comparing results between institutions.
There was still variation in these factors among the reports being analysed, as noted in the classes usedas samples. The common ideas and thoughts expressed in student reports can also be compared withthe teaching materials used, and there is an existing analysis made by Maekawa (2002) of a number ofreports in the classes from 1990-2001. The comments in all discourse were discussed anonymously torespect privacy. Both thematic comparisons in the same classes and personal moral development overthe course of lectures (and in some cases over several years) were made.

50

10

60

40

20

50

20

40

20

10

f

Number ofReports

Both sides of view

Personal versus
OthersScientific Fact

Environment /Biocentric

Utilitarian

RightsPrinciples /keywords

Quantitative facts

Gender

f

0

0

33

0

0

0

33

0

3

15

m

0

30

20

40

40

0

50

80

10

30

m

0

30

30

50

20

40

20

40

10

30

m

0

22

44

56

22

0

11

89

9

30

f

0

20

30

30

10

10

10

60

10

30

m

0

22

11

45

33

0

45

78

9

30

m

11

45

22

22

22

33

22

78

9

30

f

0

17

17

25

25

17

17

58

12

40

m

0

42

25

33

17

17

17

67

12

40

m

0

25

13

50

38

25

25

63

8

30

40

13

38

38

15
23

54
31
23
8
m

40

12

25
25

58
9
9
0
f

9

67

0
22

67
33
33
11
f

6

50 100 50

17

30
30

50

0
0

17
17
17
0
m

30

6

50

33

17
50

17
33
33
0
m

30

10

50

10

10
40

40
10
10
10
f

30

8

75

13

13
13

13
13
25
0
m

30

10

50

20

0
0

10
30
20
0
m

30

10

30

30

10
30

40
10
30
0
m

30

9

78

11

33
11

33
22
33
0
f

30

6

50

0

17
17

17
17
0
0
f

30

9

78

11

33
33

11
22
33
22
f

30

7

71

43

29
29

29
29
14
0
m

40

12

50

9

17
33

58
50
9
9
m

40

10

50

50

10
30

30
10
40
0
m

30

5

40

20

0
20

40
20
20
0
f

30

9

78

17

0
33

33
11
11
0
m

40

10

60

30

0
10

70
30
0
0
m

30

8

50

13

38
25

13
50
50
25
f

Asia-Pacific Perspectives on Bioethics Education

f

0

17

33

33

17

17

50

67

12

40

432 431 429 428 427 426 425 424 423 422 421 420 419 418 417 416 415 414 413 412 411 410 409 408 407 406 405 404 403 402 401

Classes

Code

Table 1: Summary of student and keywords to follow personal trends (%) (Results of analysis and evaluationof reports from trials in 2004 at the University of Tsukuba)

111

50

0

Both sides of view 89

0

11

11

33

0

11

11

f

Personal versus
OthersScientific Fact

Environment /Biocentric

Utilitarian

RightsPrinciples /keywords

Quantitative facts

Gender

f

0

17

17

17

0

17

6

9

Number ofReports

30

30

f

0

20

30

30

20

20

20

100

10

30

f

0

0

33

0

0

0

33

67

3

30

f

0

0

40

20

20

20

20

80

5

30

m

20

0

0

0

20

40

20

40

5

30

f

17

17

17

17

0

17

0

100

6

30

m

0

0

17

33

17

17

0

33

6

30

f

33

33

33

33

0

0

33

33

3

30

m

0

17

0

0

17

0

17

67

6

30

f

13

13

25

63

13

50

13

63

8

40

m

0

20

0

20

0

40

20

80

5

30

m

0

0

17

0

17

17

0

50

6

30

f

25

25

25

0

0

25

0

0

4

30

f

40

0

0

40

20

20

20

100

5

30

f

0

0

0

0

0

50

0

50

4

30

f

17

17

0

33

0

17

0

83

6

30

f

0

22

56

11

0

23

33

56

9

40

f

33

67

67

33

33

33

0

67

3

30

m

0

20

20

0

0

0

20

80

5

30

f

0

0

0

33

0

0

0

67

3

30

f

33

50

17

0

17

17

0

0

6

30

m

0

0

33

17

0

33

17

67

6

30

f

0

0

0

20

20

0

20

80

5

30

m

0

38

0

38

13

13

0

75

8

40

m

25

0

25

25

0

0

0

50

4

30

326 325 324 323 322 321 320 319 318 317 316 315 314 313 312 311 310 309 308 307 306 305 304 303 302 301

Classes

Code

Table 2 (part 1): Summary of student and keywords to follow personal trends (%) (Results of analysis andevaluation of reports from trials in 2003 at the University of Tsukuba)

Asia-Pacific Perspectives on Bioethics Education

112

339

10

3

67

0

0

0

67

33

0

0

m

Code

ClassesNumber of Reports

Both sides of view

Personal versus
OthersScientific Fact

Environment /Biocentric

Utilitarian

RightsPrinciples /keywords

Quantitative facts

Gender

f

0

100

50

0

0

50

50

50

2

10

338

f

0

20

40

40

0

20

0

80

5

20

337

f

0

33

50

50

0

0

0

17

6

20

336

f

0

33

33

33

33

0

67

100

3

10

334

f

0

33

17

17

0

0

0

50

6

30

333

f

42

9

33

42

33

42

33

83

12

30

332

330
30
6
67
0
33
0
17
0
0
0
f

331
30
9
22
22
33
11
11
33
33
33
f

m

8

16

8

25

8

0

33

67

12

50

329

Asia-Pacific Perspectives on Bioethics Education

f

0

33

33

67

33

0

33

100

3

10

335

m

25

0

0

50

25

25

25

50

4

30

328

f

17

17

17

17

17

0

17

67

6

30

327

Table 2 (part 2): Summary of student and keywords to follow personal trends (%) (Results of analysis andevaluation of reports from trials in 2003 at the University of Tsukuba)

113

Table 3: Summary of keyword frequency in different class reports (%) (Results of analysis andevaluation of reports from trials, in 2003-2004, at the University of Tsukuba)
Coding: N= Number of reports; D=second year students; R=third year students; B=bioethics class (mixed);
BG=Bioethics and Genes (mixed); EE=Masters’ level Environmental Ethics class. Reports in series over time by last
number, 1,2,3 etc.
Code

Report title

N

BV

PO

SF

EB

UV

R

PK

QF

4D1

Gene therapy
Cosmetic tests inanimals
Intrinsic/extrinsic
animal ethics
Genetic test results
Truth telling
SARS quarantine forstudents
What are values
Examples of cruelty
Animal experiments
doneGene therapy

17

82

29

35

0

0

35

82

12

Average
ideas
18

15

53

14

53

67

53

33

7

14

10

4D2
4D3
3D1
3D2
3D3
4R1
4R2A
4R2B

114

Asia-Pacific Perspectives on Bioethics Education

4R3
4R4
4R5
4R6
4R7
4R8
4R9
4R10
3R2A
3R2B
3R4
3R5

3R6
3R8
3R9
4B1
4B2
4B3
4BG1
4BG2
4BG3
3B1
3B2
3B3

Whale Rider movie
Fertility and lifestyle
Restrictions on
donor insemination
Thanking organ
donorsFrankenstein
Ethics of GMOs
Genetic privacy
Risks of genetic
testing
Sister tests positive
for BRCA1What affects fertility
Government
funding fertility
treatment
Differences
inheritable andnon-inheritablegene therapy
Testing cosmetic
safetyEuthanasia
Would you eat atalking cow?
Living will
Use of brain tissue
from a 12 week oldaborted foetus
GM food for world
hungerCloning
Gene therapy
conditions
Humanisedchimpanzee
How to use my lastweek
Ecotourism

Coder
1
2

14

100

29

0

86

86

0

79

0

31

?

17
18

94
78

48
17

12
0

0
0

48
6

94
6

0
0

0
0

18
28

3
1

20

15

40

35

0

90

35

60

5

17

2

25
12

0
25

80
9

0
17

12
50

24
17

4
25

12
25

0
9

27
14

3
2

18

33

28

11

78

94

6

61

0

16

2

30

67

20

30

17

77

3

30

3

15

1

23
26

87
73

13
27

0
15

8
0

13
0

9
88

26
8

4
12

25
23

1
3

26

62

15

0

0

8

31

8

0

16

3

25

56

28

0

0

40

4

20

0

17

2

27
25
24

78
80
67

7
54
17

15
24
21

33
76
29

52
44
17

48
16
4

63
16
9

0
12
0

12
19
30

2
2,3
1

14

71

7

14

0

0

0

0

14

21

3

18

39

0

22

0

0

0

0

11

21

3

30

67

3

47

7

10

0

7

10

15

1

28

29

4

4

4

43

21

0

18

20

3

29

83

14

14

0

10

14

3

0

19

3

24

88

42

13

33

33

25

54

13

31

1

23

48

0

0

0

0

24

4

9

22

3

6

100

17

33

100

33

17

67

0

12

2

10

50

0

0

0

20

10

10

0

41

1

10

60

10

10

10

20

20

80

0

25

3

22

73

9

14

41

9

0

9

14

24

?

22

45

23

45

9

27

23

32

0

19

2

21

95

0

10

0

5

10

33

5

23

3

12

58

33

8

16

16

58

100

0

41

1

11

0

9

0

0

56

0

0

0

24

3

9

0

0

0

100

0

0

0

11

25

3

3BG1
3BG2
3BG3
3BG4
2B1
2B2
2B3
2BG1
2BG2
2BG3
4EE1
4EE2
3EE1
3EE2
3EE3
2EE1

2EE2

Organs from aprisoner
Ethics of GMOs
Good and Bad
Genes
Cloning images
after movies
Teachers clone
good students
Why I don’t eat
humansChoosing kidney
recipient
Cloning classdebateShould we use GM
plants?
Donate DNA to agene bank
Abortion ofhandicapped
foetusWhat I can do forenv. ethics from myrelation to nature
Why I would not
eat a dog
Ecotourism
Ethics oftransportation
choices
Environment/
Holidays question
Bioethics principles
guide international
policyShould we give
great apes equal
rights to humanbeings?

11

45

64

18

36

64

91

9

0

17

2

11

91

18

9

82

73

0

55

0

21

3

11

100

9

64

27

27

0

9

0

28

2

10

0

0

0

10

0

30

0

0

8

3

10

100

50

30

30

90

30

40

0

16

2

12

67

17

8

25

25

25

58

0

31

1

11

82

54

27

0

36

27

63

18

24

2

13

85

31

38

23

31

54

38

0

19

2

25

76

8

44

48

52

0

32

20

24

3

27

81

8

0

8

33

19

11

8

18

3

29

59

45

42

0

52

62

59

6

22

2

15

0

7

13

13

93

7

20

73

32

3

17

94

16

5

100

47

5

0

16

35

3

13

0

0

0

69

0

0

0

38

38

3

11

82

2

72

100

46

27

64

45

31

2

17

0

0

0

100

0

0

6

6

23

3

14

64

14

7

50

20

43

71

29

80

1

16

100

31

19

44

50

100

56

25

79

1

Results
In these pilot studies there was some examination of the reliability of coding and variations relating
to factors including user of the coding frame, topic, ability and age of students. The most significant
predictor of the student response to a given topic in a report was the student themselves. In otherwords students who had scored positive on each of these indices for one code were more likely toscore positive in a future report, even one year later, and the contrary also held true for those startingout negative for the keywords. What is interesting is the few cases where scoring of students for someindicators of bioethical education improved over time, for example, some students did increase thefrequency of giving both sides of view, or of mentioning environmental or biocentric thinking. Thesechanges could be reinforced by the teacher, and in fact these trials suggest that without such positive
feedback the students will not change their report writing.
This tendency not to increase the frequency of scoring positive for bioethical indicators in reports is
despite an increase in oral discussion through the classes of the students’ ability, commonly found inall students. This also means that in oral tests of critical thinking students would score higher after theclasses, but in their reports it was difficult to see unless a more complex discourse analysis was used
to examine the main ideas of the reports and the degree of argumentation used. As an evaluation
methodology it appears that the best for reports is a total textual analysis of the types of argumentation
used, following the case of Kohlberg given above.
Changes in the frequency of keywords and concepts need to be measured against several variables,

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3B4

115

including internal factors connected to the class such as the wording of the title, the nature of thematerials used, the comments given by the teacher, and the comments made during the class. For
reports in the classes analysed here, the students must discuss and question others’ opinions, and foranalysis of class discourse there was audio recording of classes and debates. Text analysis of the reports
for keywords using the above methods can be conducted and then discourse in the class compared.
Trials of the textbook as a whole and all chapters were conducted over several years, and the results will
be assembled in the future.

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One of the observations of this report analysis is that utilitarian views appear to be more person-specificrather than varying with the topic, more clearly than other keywords. Gender trends were examined.
There may be a trend that students who took bioethics classes use more principles and keywords,
however, it is not clear if this is because of the bias of students choosing the subject or the styles ofteaching and class content. Table 1 includes a student code number for analysis, the number of classes
they had attended (75 minutes each), the number of reports analysed from that student, then thepercentage of reports that included the items under the coding system.
There were found to be more topical trends in the use of keywords as shown in Table 3. Some are
obvious, for example, we would expect students to mention the environment or have a biocentric
view if the report was about animals or the environment, than not. A report specifically with rights inthe title may make the student use the term rights rather than general principles like autonomy. It is
important to modify keywords for specific research purposes and essays, extending this list. This initial
keyword analysis will short cut a full qualitative analysis, and allow for greater ease in making crosscultural comparisons between languages. Still a list of example sentences for each coding point in eachlanguage would need to be made to ensure that the persons coding have the same standard.
The reports written by Master’s students in environmental ethics (EE) generally have a greater numberof ideas, which is partly related to the generally longer length, but also due to the older age of thestudents. However, still the frequency of keywords seems to be related more to the topic than any otherfactor. The greater maturity in terms of experience and age did not correlate strongly with a greater use
of keywords, except for the higher frequency of eco-centric viewpoints.
There is some comparison made of three coders (persons who did the initial report coding) for thereports in Table 3. This means that checking and discussion amongst coders is needed, and experience.
In general, coder 1 scored a greater number of ideas, although attempts were made for standardisationof coding and for checking of initial coding.
A further possible step in confirming the results from the analysis of the reports is to examine the taperecordings of class discourse to see how students initially discussed these topics and then later after
being explained more bioethical principles relating to the analysis of the topics, that they then modified
their argumentation.
What has become apparent from the analysis of student trends and total class trends is that the greatest
factor in the use of keywords is not time, rather it is more dependent upon the person, the topic, thereport title, and the materials used. Therefore to examine the progress of moral development requires
more detailed discourse analysis of the report, or an oral interview.

Discussion
There were also extrinsic factors such as news stories at the time of the report. A commonly used sourceof material in many schools is newspaper articles and cuttings. Teachers would sometimes take two
opposing articles and have the students discuss them. For many years prior to the development of the
textbook, I used short articles from scientific journals, such as the New Scientist or “News and Views” fromthe journal Nature, to have the most current scientific debates as a starting point for discussion.
There are also cultural values and family values that affect the reports, as well as the total educational
curriculum. Students may introduce ideas from many other sources. Despite the popular belief thatmovies do change ethical attitudes, very few students cited movies in reports. However, when students
were asked to write about movies they all mentioned many movies that had bioethical/ethical issues

related to science and technology. From the reports, it seems that the integration of concepts they had
seen in movies into class reports was uncommon – perhaps mentally they had distanced these. It will
be an interesting research question to see how the earlier introduction of movies about ethical issues
into the teaching course will open up sources in the integration of values from movies into academic
lessons.
This study does not give conclusive evidence that the process of Kohlberg’s stages of development isuseful in this context. Moreover, the goals of bioethics education are not usually construed to follow
the ideas that Kohlberg described, thus the evaluation tools that were developed did not follow thatmodel of moral development. Educators of bioethics are looking for the types of categories exploredby these keywords, and careful choice of topic and material can effect change in the outputs learners
make. Whether that leads to lasting value change is not known, however the comments to both thequestionnaires and the comments students give back at the end of the lecture series in different
countries have been positive.

Acknowledgments

References
Macer, DRJ., ed., 2004. Bioethics for Informed Citizens Across Cultures. Christchurch, N.Z.: Eubios Ethics
Institute.
Maekawa, F. 2002. Developing an Analytical Method to Evaluate Bioethics Education: Results from Classes
Conducted at the University of Tsukuba. M.Sc. Thesis, University of Tsukuba.
Maekawa, F. and Macer, DRJ. 2005 How Japanese students reason about agricultural biotechnology.
Science and Engineering Ethics, Vol. 10, No. 4, pp. 705-716.

Asia-Pacific Perspectives on Bioethics Education

The authors would like to thank the Sasakawa Peace Foundation for their essential financial support
through the form of a grant to the Eubios Ethics Institute. We thank the many students who wrote thereports.

117

Teaching Compassion*
Shigeo Nagaoka, M.D.
Niigata University, Japan

What people desire from medical professionals

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It is widely accepted that there are two things patients want from medical professionals: Competence
and compassion. Every patient hopes that doctors, nurses and others involved in the treatment of his
illness can perform their works properly, and hopefully, superbly. Moreover, confronted with unexpectedor serious (from a personal point of view, and not necessarily medically) medical problems, they will findkind words or compassionate acts from medical providers very encouraging and helpful. Hence medical
education aims to teach not only high skills in medical practice, but also to foster compassionate andsympathetic attitudes in future medical professionals.
But there is a difference between these two goals. Competence may be measured more or lessobjectively. For instance, a doctor’s ability to diagnose disease, to prescribe proper medication forthat problem and so on can be measured by the outcomes. Due to the ever-increasing complexities inmedical settings, it has become more and more difficult to realise high competence in future medical
professionals. However, at least the goal is clear.
On the other hand, compassion is an elusive goal. Whether an act is seen as compassionate or not
depends on the context. However hard one tries to be kind to others, the intention does not automaticallytranslate into appreciation, explicit or implicit, of kindness by them. There is no such thing as objectively
compassionate behaviour or objectively kind words. Compassion or kindness is an evaluative judgment,
made by the other partner in the interaction, and therefore influenced by the nature of the interaction
as well as the mental states of the other partner. Herein lies the difficulty of teaching compassion in theformal curriculum of medical education.

Cultivation of compassionate attitudes
There could be two ways to teach compassionate attitudes in medical education. One is what I would
call the general approach, and the other the specific approach. The former concentrates on characterbuilding, while the latter uses the case method, showing what acts or words are seen as compassionate
in each particular situation.
The general approach aims to teach the students to be virtuous, first and foremost. Since compassion
is one of the cardinal virtues, they are expected to become kind and compassionate too, after the
successful completion of the educational curriculum.
But one wonders if people can teach others to be virtuous as such, abstractly and without examples.
Saying simply: “be virtuous” will not produce any effect. We may recall that even the German philosopher,Kant, who emphasised the purity of motive in morality above all, proposes, when it comes to moral
education, to start from the students’ examinations on whether a particular action is in accordancewith the moral law externally, in the section titled “the Methodology of Pure Practical Reason,” in his
Critique of Practical Reason (Kant, 1788). He was well aware that people cannot have pure minds, freefrom sensual influences, from the very beginning, but have to take steps to purify their minds withthe accumulation of particular experiences. This consideration suggests that the general approach iseffective only when supplemented with a specific approach.
Furthermore, there arises another doubt, when we concede that the general approach alone could
produce the intended educational result. This approach assumes that once someone becomes virtuous*

Paper first presented at the joint UNESCO:UNU-IAS Roundtable on Japanese Perspectives on Bioethics Education
held in Yokohama, Japan in February, 2007.

and has full knowledge of the circumstances concerned, whatever she does is bound to be virtuous, and,more specifically in this context, also to be kind and compassionate. To many people, this assumption
will seem too optimistic. Our everyday experiences tell us that we cannot be wise in our everyday
transactions until we have learnt, step-by-step and bit-by-bit, what the world is like. To act properlyin this world, purity of motive is not enough. It has to be supplemented by the knowledge of what
people are, what they think and what they do. Even if this assumption should ever be applicable tosome exceptional few people, it is certainly not the case with the many who hope to become medical
providers.
Hence we are led to the second alternative, i.e. a specific approach. This aims to teach how to be kindin each particular situation. That is, the students are supposed to understand each patient’s particularsituation at each moment, and then to accommodate their behaviour to ever changing mental states ofthe patient. In educational settings, cases and vignettes, actual or fictional, are often utilised to induce
students to think what actions to take in various situations. This method is widely supported, especiallyby those who stress the role of dialogues in the patient-medical provider relationships, or who present
the ideal of shared decision making in the informed consent doctrine

If medical providers are conscientious, they will take seriously the task, or even the duty, of being
compassionate. The enormity of the task will eventually overwhelm them and may lead to some form of
burnout on their part. Schneider (1998) puts this point very well:If this [kinder care] means assuring patients that doctors and nurses are genuinely motivated bydeeply felt concern, that they truly empathize and sympathize with their patients, and that they
will manifest those feelings at every turn, the effort is hopeless. Insight and concern are fragile
plants, and they wither easily when they must be mustered routinely for every person, however
boorish and belligerent, who comes along. (Schneider, 1998, p.220) [parentheses mine]
Another problem is that the appreciation of kindness depends on the context, as was pointed out above.
It is commonplace to observe that in our everyday life, what we intend to do to others is not necessarily
so understood by them. The following example illustrates this point:
One young lawyer with ovarian cancer told me: “I didn’t want to understand about my own
cancer; it was too distressing and scary. I didn’t want to know the survival statistics or how fast
the tumours grow. I had broken up with a boyfriend just before my diagnosis. In trying to be
helpful, he came over with a book that was full of this kind of information. I told him, “No, I don’t
want to read this. He told me he thought it was something I needed to do. And I felt like I wasn’t
being a good patient.” (Gruman, 2007)
At this particular moment, his apparently kind act produced an opposite effect and turned out to be
hurtful to her. But it is not unlikely that, if her ex-boyfriend had done the same thing a week later, when
she had regained her strength somewhat, she could have been very grateful to his act. She might havesaid: “I want to know what is going to be done to my body, and this is exactly what I want to know.” So
the timing may be very important, and we may add, it will be humanly impossible to know in advance
exactly when the time is right to do so.
What matters is not only the timing of doing a certain act. Also, what kinds of actions patients consider
to be kind and sympathetic is diverse. For instance, the diagnosis and prognosis of a patient’s conditionis the most basic information medical providers give to her. Sometimes this information has somesoothing effect on the patients, sometimes it does not mean anything to them.
Eric Cassell (1985), at the very beginning of The Healer’s Art, recalls an enigmatic therapeutic effect his
explanation of the expected course of change had on a patient with full-blown pulmonary edema(water in the lungs) resulting from a blood clot in her lung.

Asia-Pacific Perspectives on Bioethics Education

But one worry is that this may be too demanding for them. Doctors and nurses encounter many people
every day, most of them being strangers or at least near strangers. Even when they know a patient
rather well, like a hospitalised patient, still it is not easy to see what he or she is thinking about or isworried about at that very moment, let alone to see the intensity of the worry.

119

“I stood at the bedside feeling impotent, but the old woman’s face and her distress pleaded forhelp. So I began to talk calmly but incessantly, telling her why she had the tightness in her chestand explaining how the water would slowly recede from her lungs, after which her breathing
would begin to ease bit by bit and she would gradually feel much better.
To my utter amazement that is precisely what happened. Not only did her fear subside [which
would not have surprised me] but the noises in her chest disappeared under my stethoscope,
giving objective evidence that the pulmonary edema was, in fact, subsiding. By the time theequipment came, things were already under control and the patient and I felt as though together
we had licked the devil.” (Casssell, 1985, pp.13-4)
Here Cassell emphasises the therapeutic effect and does not talk in details about how the patient’s
mental state changed through his talk: he says only “Not only did her fear subside.” But undoubtedly,
this is because his explanation was perceived to be caring and compassionate by the patient.

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But this type of information does not always bring about the expected result. Rather, some other remark,which the speaker would not have anticipated to mean much, might have the same effect.
“It is often sympathy that people want rather than concrete assistance or advice about how tosolve their problem. . . . I observed an elderly white woman hospitalized with a crushed hip. She
told her nurse (and everyone who came within hearing range) that she had spent a difficult night.
The nurse first responded by arranging the bedding to try to make the patient comfortable, but
the woman kept complaining. Next, the nurse offered advice: “If you just eat more and take your
medication, you’ll feel better.” The patient’s reaction was to repeat the details of her tortured
night. Finally, the nurse said: “I know how you feel.” “Thank you for your sympathy,” the woman
said, and she immediately relaxed her taut muscles, wiped away her frown, and lay back on her
pillow to sleep.” (Clark, 1997, p.19)
Here the nurse hoped the information about her diagnosis and prognosis would help the patient, but
it did not succeed. Probably as a last resort and not hoping for much, simply she said: “I know how you
feel.” Maybe much to the surprise of the nurse, it calmed the patient’s mind.
A caveat. In the above quote, the author contrasts sympathy with concrete assistance or advice. As
we noted in the first section, sympathy is a subjective judgment made by the patient, while concrete
assistance or advice can be observed by third persons. The phrase “I know how you feel” was perceived
to be sympathetic on this occasion, but even in similar circumstances it could have been seen as an oldcliché. Or, as in Cassell’s case, the latter also could be perceived to be sympathetic.
We have seen two problems involved in the specific approach, though it is widely adopted in medical
education. One is that it requires too much from medical providers and it might lead to a burnout. The
other is that, however hard one tries to read the patient’s mind, there is a limit to the degree one canfathom the nuances of ever changing mental states.

What is involved in the appreciation of compassion?
We have noted at the outset of this essay that the appreciation of compassion by patients depends on
the nature of the interaction between patients and medical providers. In order to see more clearly what
the nature of the interaction is all about, I would like to look into the arguments put forward by two
British philosophers, David Ross and Henry Sidgwick. Though their discussions are not about medical
encounters but about morality in general, I will try to show that they offer significant insights into therelationships between patients and medical providers: from Ross, luck as an indispensable ingredient of
the appreciation of compassion, and from Sidgwick, patients’ perception of compassion is a by-productof some acts by medical providers, since aiming to be kind to patients directly does not necessarily
produce the intended result.
Ross is famous for his distinction between prima facie duties and actual duties. An actual duty is what
we should do morally in a particular situation, while a prima facie or conditional duty is what will become
an actual duty, if the contemplated act has no other competing significant moral characteristics. Basedon the representative human relations, he enumerates seven prima facie duties: 1) fidelity; 2) reparation;3) gratitude; 4) justice; 5) beneficence; 6) self-improvement, and: 7) non-maleficence. When one act
fits with one of the categories and does not conflict with any other, it will be an actual duty in thecircumstances. On the other hand, if one act satisfies one category but infringes another, we are facedwith a difficult task of discerning what our actual duty really is.
“Our judgments about our particular duties...are not self-evident. Where a possible act is seen tohave two characteristics, in virtue of one of which it is prima facie right, and in virtue of the otherprima facie wrong, we are (I think) well aware that we are not certain whether we ought or ought
not to do it; that whether we do it or not, we are taking a moral risk. We come in the long run,after consideration, to think one duty more pressing than the other, but we do not feel certainthat it is so.” (Ross, 1930, pp.30-1.)
Where two rules conflict with each other, we are at a loss what we should do, and even if we gather moredata about the situation and analyse them in more details, feeling closer to the right judgment, there
always remains a possibility of making a wrong judgment.

There are cases where a contemplated act seems to relate only to one prima facie duty. If this is the case,
it is straightforwardly the actual duty. But we cannot exclude a possibility that due to the complexity of
the human world, the act might indirectly impinge on another prima facie duty.
“There is therefore much truth in the description of the right act as a fortunate act. If we cannot
be certain that it is right, it is our good fortune if the act we do is the right act.” (Ross, 1930,
p.31.)
Ross’s observations on moral duties illuminate the nature of the interaction where some acts are judged
to be kind and compassionate. There are many rules of thumb which tell us what to do and say topatients in medical encounters, such that our acts are likely to be appreciated by patients as kind andcompassionate. But they are only rules of thumb and there is no guarantee that those acts would be
judged to be sympathetic. There is always a risk (like Ross’s “moral risk”) that those acts do not have any
impacts at all, or worse, even hurt the patients’ feelings at the particular moment, as we saw in the caseof an ovarian cancer patient in the last section. However hard we try to utilise our conventional wisdom
to show kindness to patients, our acts would be judged to be compassionate only when good luck is
on our side. The lesson from Ross’s thoughts is that luck is an essential ingredient in the appreciation ofcompassion.
Now we turn to Sidgwick (1907). We will summarise briefly his discussion on the fundamental paradoxof hedonism, with a view of showing that directly aiming to be kind does not always bring about theintended result. Sidgwick distinguishes between the pleasures of Attainment and the pleasures of
Pursuit. The former are felt when we attain the goal we pursue, like the satisfaction of hunger when we
finally have a bite. On the other hand, the latter are felt when we are engaged in some eager activity,
like a competitive game. In this kind of game, an initial desire to win the game is stimulated a great deal
when the competition becomes intense, and then the contest itself becomes pleasurable, if things go
well.
In other words, with the initial goal of victory working as a starter, the contest or pursuit itself gives us
pleasurable experiences. Here in this pursuit, the agent does not aim to obtain pleasures, but only tries
to win the game, with pleasures coming to him as by-products of the activity. Therefore, in the case of
our active enjoyments especially, he observes that “the impulse towards pleasure, if too predominant,defeats its own aim,” and calls it the fundamental paradox of Hedonism. (Sidgwick, 1907, p.48.) And thereason why he singles out the latter group as the basis of his general paradox thesis is that the pleasuresof Pursuit are thought by many to be more important and fulfilling than the pleasures of Attainment.
Though Sidgwick’s discussion is about self-regarding experiences, it can be extended to other-regarding

Asia-Pacific Perspectives on Bioethics Education“And though we do not always recognize that a possible act has two characteristics, and though
there may be cases in which it has not, we are never certain that any particular possible act has
not, and therefore never certain that it is right, nor certain that it is wrong.” (Ross, 1930, p.31.)

121intentions. There may be two types of situations where we express gratitude. One is where what wewant is clear and it is satisfied, like asking the directions to a station in an unfamiliar place and receiving
the appropriate information from a passerby. The other is where we are not sure what we need, nor are
the people around us. Taking Clark’s example from the second section, the lady with a crushed hip kept
complaining about her ordeal, not knowing what will calm her distress. The nurse tried three things:
arranging the bedding, advice, and a simple phrase “I know how you feel.” Rather than the first two, thelast one, seemingly the most insubstantial, worked and elicited words of gratitude.
Therefore, we may be able to distinguish two types of gratitude. One is the gratitude we show to others,
when they perform what we ask for, while the other is the gratitude we feel, when we are in serious
trouble and despair, not knowing what to do, and something relieves us from the pains and sufferings.
When people with life threatening diseases say they would like to receive encouragement from medical
providers, quite often what they mean is the second type of relief, a kind of salvation from the bleak
reality they are thrown into. Like the pleasures of Pursuit, this second type of gratitude feels more
impressive and has a far deeper impact on the patients’ mental states.

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Seen from the point of view of people offering kindness, the first could be tentatively called compassion
in attainment, and the second compassion in pursuit, adapting Sidgwick’s phraseology somewhat tothe present context. Those medical providers who want to be compassionate to patients may try tolearn and perform various skills in the area of compassion in attainment: the proper beddings so thatpatients can feel comfortable, the accurate information disclosure so that they can foresee what will
likely happen to them in the future, or simple words like “I know how you feel.”
These acts or words may have some good effect on the patients’ psychology, or as often, may be simply
taken for granted. These are matters of luck, as Ross emphasised. But luck works at a deeper level, too.
As for the more important type of compassion, i.e. compassion in pursuit, people cannot aim to becompassionate in this sense. Like the pleasures of Pursuit, this type of compassion is realised when they
are engaged in some other activity, without having compassion in mind and when luck accompanies
it. The appreciation by patients of compassionate attitudes at this level is a fortunate by-product of theactivity seemingly unrelated to this kind of compassion.

Then, what sort of training?
In the second section, we saw the problems when we attempt to teach compassion. The problems in
the general approach are 1) a doubt about whether it will produce the result hoped for, and 2) a doubt
about whether every deed a virtuous person performs will be virtuous (this is an important topic in
virtue ethics, which we cannot discuss in more details here). The problems about the specific approachare 1) a worry that it may be too demanding for medical professionals to be well versed in and meetmany patients’ various needs all the time, and 2) an observation that patients’ needs are so diverse that
it is almost impossible to act in a way they would thank for the expression of kindness.
In the third section, we have learned that whether we act compassionately or not depends a great deal
on good luck, not simply on our intentions and that the judgment of compassion by patients is quite
often a by-product of some actions we do for other purposes.
Then, what sort of training is desirable, to foster compassionate attitudes, or more precisely, to help
perform actions which are likely to be judged compassionate by patients?
Schneider’s suggestion in The Practice of Autonomy seems instructive. Patients’ recollections about theirillnesses are full of stories about what horrible experiences they underwent, or how badly they weretreated. He suggests that we should, first of all, try to minimise those awful experiences. Since thoseexperiences are also subjective judgments made by patients, like the judgments of compassion, andmoreover they are made by people in difficulties, there may not be any system which guarantees toeradicate those experiences. Therefore, he proposes to start from seemingly trivial matters, i.e. nottreating patients badly, or treating them decently.
This is mainly matters of manners and civility. This does not require being a really conscientious person
who likes all the patients and genuinely shares all their troubles. Simply this asks you to think about theeffect on the patients of what you do and say, and to try to avoid the actions that may result in treatingthem badly.
He proposes the following ten rules. (Schneider, 1998, pp.221-226.)

Many of the rules are such matters of fact that these may seem quite boring. But first we have to takenote that these are not always followed, and failures to comply with these are quite often sourcesof patients’ complaints. Second, Rule 6 shows the characteristic of his approach. “Listen to what thepatient has to say” has been said quite often, but he adds, “and seem to listen.” Sometimes you may betired of hearing the same old complaints, or sometimes you may get impatient with the patients’ slow
understanding of the information. You do not have to feel guilty of having those feelings (having nosuch feelings will mean being a saint), but at least you should strive to appear to be listening. Third, Rule
8 mentions sympathy. Here, what is required is not true empathy, but some expressions of regret andconcern as part of common courtesy.
Some people may be critical of this approach, since this is concerned only with outward appearances,
not sincerity of heart. Yet as one physician notes, such little things as “a daily visit, a few minutes offriendly conversation, or sometimes just a new young ear to hear the old story all over again” (Zuger,
2007) make huge differences.
If we follow these rules, the relationships between patients and medical providers may remain moreor less businesslike or contractual, but sometimes the attitudes of the medical providers may beappreciated as showing compassion, with good luck, and as a by-product of their activities. After all,compassion is cherished so much because it is rarely felt.

References
Cassell, E. 1985. The Healer’s Art. Boston, MA: MIT Press.
Clark, C. 1997. Misery and Company: Sympathy in Everyday Life. Chicago: University of Chicago Press.
(quoted in Schneider, Practice of Autonomy, p.199)
Gruman, J. 2007. How Much Do You Want -- or Need -- to Know? Washington Post, February 6, 2007
Kant, I. 1788. Kritik der praktishen Vernunft [Critique of practical Reason].
Ross, D. 1930. The Right and The Good. Oxford: Oxford University Press.
Schneider, C. 1998. The Practice of Autonomy. Oxford: Oxford University Press.
Sidgwick, H. 1907. The Methods of Ethics, 7th ed. Cambridge: Cambridge University Press.
Zuger,A. 2007. The Difficult Patient, a Problem Old as History (or Older), New York Times, March 6, 2007

Asia-Pacific Perspectives on Bioethics Education

Rule 1. Do not keep people waiting.
Rule 2. Respect privacy.
Rule 3. Introduce yourself to strangers.
Rule 4. Grant other adults the same courtesy in titles you accord yourself.
Rule 5. Take the time you need to talk to the patient.
Rule 6. Listen, and seem to listen.
Rule 7. Say “please” and “thank you”.
Rule 8. Express sympathy when you deliver bad news
Rule 9. Return your phone calls.
Rule 10. Think about the effect on your patients of what you do and say. (This is the generalprinciple from which the rest follow and from which other obligations may be inferred.)123

Can formal education promote beneficence?*
Arockiam Thaddeus, M.A.
Jayaraj Annapackiam College for
Women at Periyakulam
Jothi Rajan and T. Mathavan
Madurai Kamaraj University
V. Fragrance Latha
Government Higher Secondary
School at Thiruvadavur, India

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Introduction
Most people find it very difficult to say, in specificity and in detail, what their own values are. Somedistinguish positive values from negative values. Some categorise values by content or source: aesthetic,
economic, religious, and political. Values are very easy to speak about but much harder to follow. Values
are abstract ideals. Sociologist Dennis Foss defined values to mean “beliefs about classes of objects,
situations, actions and wholes composed of them in regards to the extent that they are good, right andobligatory or ought to be”.

Bioethical Principles
Bioethical principles usually include respect for the “person” and personal autonomy, non-maleficence(primum, non nocere; “above all, do no harm.”), beneficence (helping, caring, offering compassion andcharity) and pursuit of justice. Unified morality is scarcely seen among individuals. Even the organised
religions have not helped much. Keeping this view in mind, and to fill some lacunae in the moralityof people, a perspective on a single value – beneficence – was taken for the present study. This canbe achieved only through education, education at home, school and the society (family), and allow
humans to regard themselves as a mine rich in gems of inestimable value. Tagore said that school is thelap of the mother for the child. Education alone, can cause is to reveal its treasures and enable mankind
to benefit there from.
There is a symbiotic relationship between “education” and “development”. The two are very vitalsocio-economic, political and cultural activities of the modern world, though this relationship is notgetting much attention in our discourse upon education. Although nations, like persons have different
characteristics, needs and goals, there are certain common human values that drive the world’s
population. There is justification for adopting certain educational systems based on the common
cultural heritage of humankind. But there is the simultaneous need for making education relevant to
the immediate social environment. Alternatively, the educational system of a nation should develop in a
cultural environment that has historical validity. Most experts would agree that education is the process
by which a human being learns facts and skills, develops abilities and attitudes for personal benefits first
and then hands them down to the next generation along with the cultural and moral values imbibedthrough the process, all of which depend on the educational priorities and goals of the people. Persons
who are educated develop physically (economically), mentally, morally and socially. They are likely toknow the “whys” and the “wherefores”, of events and issues surrounding them. They can map theirworld, their immediate environment and live a more meaningful life.
We cannot give to anyone what we do not have. Only if we are the educated group, can we educate theworld at large. The formal agencies of education are schools and colleges. The important characteristics
of formal education are deliberate, staffed, financially supported, time-spaced and fixed procedures.
Though the value “beneficence” can be included as one of the topics in the curriculum, the essence of
its success in implementing it and to touch the heart of the pupils entirely depends on the classroom*

Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005.

teacher. Politicians, who are the policy makers and the administrators of the educational system, only
evolve a theoretical background for an intensive practical fieldwork, which is to be carried out by theclassroom teacher.

The art of teaching
Teaching is derived from the root word taikjon which means “show how”. Teaching involves difficult,complex series of functions. It is indeed a profession in terms of the demands it places upon its
practitioners. It is probably even more difficult than medicine itself. Though teaching is one of the oldest
professions, as old as humankind and has been with us for a long time, a unified conception of teaching
acceptable to all has not been arrived at yet. Teaching is an art, a science and a skill. The teacher has tohave the creative proficiency of an artist, the precise attitude of a scientist and the perfected skill of acraftsman. Teachers engage in explaining activities, guidance activities, demonstration activities, ordermaintaining activities, mental hygiene activities, record keeping activities, assignment making activities,
testing and evaluation activities and many other kind of activities. Thus the teacher’s task centres on:

Teaching is useful only to the extent that it facilitates learning. An incidental and casual approach toteaching must be replaced by a planned and conscious approach. Experimental evidence has shownthat sight is the most useful of our senses to advance learning. The percentage that we learn throughthe various senses and the effectiveness of the senses in learning are related. On average, the sense ofsight which caters to nearly 83 per cent of our learning is using much. Hearing caters to 11 per cent while
the senses of smell touch and taste caters to five per cent and one per cent of our learning respectively(unless we lack one of these senses in which case the balance changes). So the use of audio-visual aidsin teaching will facilitate better, easy and interesting learning.
The inter-relationship of various types of audio-visual aids are explained well by Edgar Dale’s Cone ofExperience (Figure 1). The cone of experience is merely a visual aid. It represents the audio-visual aid
and their effectiveness. The effectiveness of the aids increases from top of bottom of the cone. The
teacher has to choose the right type of aid to suit the situation, and the standard of students, to use if
effectively.

Asia-Pacific Perspectives on Bioethics Education• Motivating the learner towards desirable objectives;• Facilitating the attainment of these objectives through providing suitable learning experiences.

125

Figure 1: The Cone of Experience

VERBALSYMBOLSVISUAL SYMBOLSRECORDING, RADIO
STILL PICTURES
MOTION PICTURESTELEVISION

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EXHIBITSFIELD TRIPSDEMONSTRATIONSDRAMATIZED EXPERIENCESCONTRIVED EXPERIENCES
DIRECT, PURPOSEFUL EXPERIENCE
Edgar Dale’s cone of experience helps the teacher select the proper method to explain the values of
helping, caring, offering compassion and charity.

Co-Curricular activities
Field trips and excursions can play an important role in imparting noble values. Visits to zoological parks,
trips to orphanages, playing and spending time with handicapped children, visits to institutions for thementally disabled and other places of interest to the students can touch the heart of the pupil rather thebrain. In these types of visits the students may pose many questions to the teacher. The teacher has tocome to the level of the student and answer all the questions, as and when asked by the students.
A patient hearing the questions of the pupils directly or indirectly projects the teacher’s “caring” for his
students and in turn moulds his students. Thus the teacher becomes a role model for the student.
A survey conducted in our college pointed out that 50 per cent of students want their teachers to be
like their parents. They want their teacher be a friend, philosopher and guide. Nearly 80 per cent of thestudents want their teachers to be role models. Nearly 10 per cent of the students considered theirteacher to be “God”.
In every subject whether it is science, arts or commerce the values of life can be taught as an analogy.
For instance a physics teacher while teaching Newton’s third law of motion can extend this to life. The

law states: “For every action there is equal and opposite reaction”. After giving proper explanations it
can be linked to life as: “Good actions bring good rewards; bad actions bring otherwise”.
In a nutshell, teachers shape the students. The home, the neighbourhood, the community, the state,
the social, cultural and religious institutions are all informal agencies of education. For example theeducation given by successful leaders to their party members is informal. “Beneficence” experienced
informally helps in the total development of the child’s personality. It is rightly observed that education
starts at home and children begin their education from the time they are born. It may be observedthat the instinctive desires of children are vague and it is education and opportunity that can mould
them into responsible citizens. The raw material of instinct is ethically neutral and can be shaped togood or evil by the influence of the environment. Hence one has to note that it is the polluted sociopolitical environment that is causing damage to human society in general and educational institutions
in particular. It is in fact becoming increasingly popular to mourn the demise of the humanities whichreminds us of the popular verse of Henry Van Dyke:“Seven pupils in the classof Professor Callias
Listen silent while he drawls

This is problematic in the classroom as the teacher remains a source of mockery and the student fails to
see the sanctity of learning. It is this polluted environment that is having its impact on the educational
institution. Bertrand Russell’s appeal to distinguish between education of character and education in
knowledge is hardly visible. The rapid strides in the communication and information systems will bemeaningfully utilised if the print and electronic media can seriously take up the problem of education
as a social responsibility. The teacher should courageously accept the moral responsibility of moulding
the student by showing cheerful willingness in Tagore’s spirit. “Where tireless striving stretches its
arms toward perfection”. A coordinated effort on the part of the parent, the teacher and the print andelectronic media and the educational administrator will put the system back on the rails.

A true incident
Death with dignity is a value. An old terminally ill man left to die was taken to the home of Mother Teresain Calcutta. He was attended to with compassion and care. Before dying a few days later, with his eyes
shining in wonder, he said: “All my life I have lived like an animal. But now I am dying like an angel.” Herewe conclude that the institution informally made the dying person feel the gift of life. The home plays
an important role in moulding the child. The helping nature of the parents toward their neighbours andthe needy makes an everlasting mark on the child’s heart to help others as their parents do. The carewith which the parents look after their children makes an everlasting impression in their heart that theyshould take care of their parents in their old age and also care for the suffering of human beings.
In one situation, a group of nuns were collecting funds for their orphanage. One nun stood before amulti-storied bungalow and was waiting at the door to ask for alms. The head man of the house thenspat on the hands of the nun. She accepted it with grace and said: “Let me have this; give something for
my children in the orphanage”. On hearing this comment the whole family wept and begged pardon
from the nun and offered help to the orphanage. Here we see that the compassionate act of the nun
moved the hearts of family members. Though the incident is trivial, all the human virtues like helping,caring, offering compassion and charity were practiced in a small act of sacrifice and by the words: “formy children”.
Some of the great people we have encountered also possessed great virtue through guidance at home.
Thomas Alva Edison, who invented many electrical devices, had a large head not proportionate to otherparts of his body. The class teacher often remarked: “Edison! You have a big head with no brain”. This
comment pricked the tender mind of the young Edison. His mother approached the class teacher andchallenged him that one day her son would become a great person. Edison was removed from school

Asia-Pacific Perspectives on Bioethics Education

Three are benches, four are walls”.

127and educated by his parents. Later in life, Edison invented many electrical devices, including the Edison
Safety Lamp which helped miners work more safely in mines by reducing the threat of gas explosions.
Edison was not only a great scientist but also an embodiment of the virtues of a helping, caring societythat offers compassion and charity.

Family and beneficence
Thus, it is worth mentioning here the importance of the family, and particularly parents in shaping
young lives. Parents should be educated on how to bring up their children to fight the evils of society.
Parents ought to be role models for their children and “should not spare the rod and spoil the child.”
Parents should have an eye over their children regarding their studies, moving with friends, cultivating
good habits, the society around them and their physical growth. Parents should have good rapport with
their children. They should be allowed to grow in a healthier climate at home in spite of poverty andother problems.

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In the case in which learning is more incidental than intentional, we have a non-formal education
situation. It is not restricted to any particular place and time. It is a process designed not only for children
and youth but also for adults. It is an open system of education without any rigid rules, regulations andconditions. It is life oriented and environment based. It aims at socio-politico-economic growth of theindividual as well as society.

Society and beneficence
Educating a mentally disabled child needs special training. Voluntary organisations come forward toeducate mentally and physically disabled children through meagre grants given by central and state
governments. We will be surprised to know the type of education imparted to less fortunate children,
yet these voluntary organisations learn to help others. To quote an incident, I was attending the Annual
Day celebrations of a rehabilitation centre for the mentally disabled on the outskirts of Madurai City,
India. W
While I was walking my footwear broke. I approached a person, around thirty years of age, and asked
him for a safety pin. To my surprise the man took out the safety pin from his Annual Day badge which hehad pinned onto his shirt. He simply put the badge aside in his pocket and smiled at me. I was surprisedby this act of caring from a member of the centre, which is known as “Shrisiti”, a voluntary organisation
run by noble hearted people under their head, the M.S.Chellamuthu Trust and Research Foundation.
The main objective of the Trust is to alleviate the sufferings of the mentally disabled. This voluntaryorganisation is a registered non-profit, secular non-government organisation. Because a large proportionof the population in the world is semi-literate let us suggest a strategy for education. We suggest thatvoluntary organisations can make use of modern day advertising technology. Video clips of variousorganisations working for the welfare of the people could be screened during their leisure time. Most
people go to work in the fields and other places and their leisure time could be improved by giving
them a proper education to care for others and find happiness. Street plays, dances, dramas could beenacted in an effective way and thus rural adults could be educated to be instruments of the true valueof “beneficence”.
The capacity for lethal violence is particularly great in humans. The exceptional features of our intellect,self-awareness, sense of morality contribute to a life of great social complexity. A number of opponents
of socio-biology have claimed that donating blood for free is a kind of “pure” altruism practiced for no
possible reproductive advantage. The donors are supposedly behaving simply out of a moral concern
for others whom they will never meet, from whom they can receive no repayment.
According to Peter Singer (1981) “Common sense tells us that people who give blood do it to help
others, not for a disguised benefit to themselves”. Alexander (1987), however, suggests that “giving
blood is a fine way of suggesting that “one is so altruistic that he or she is willing to give up a mostdear possession for a perfect stranger.” This could yield pay offs in the future, not from the stranger but
from those who live and interact with the donor and view him as potentially more cooperative andhelpful than others who are not known to be so ‘altruistic”. Martin Daly and Margo Wilson suggest thatour brains tell us that it feels good to engage in low cost “do-goodery”. At the approximate level thisfeeling currently motivates us to give blood occasionally or exhibit other inexpensive forms of culturally
approved charity. Such a mechanism could have the generally adaptive consequences of maintaining agood reputation and facilitating reciprocal relations as Alexander claims.
Beneficence is not to be preached in a vacuum as an abstract concept, for “as the body apart from works
is dead” (The Holy Bible). Those who are practicing beneficence have to be in the forefront, working forthe people, defending their rights as citizens, as loyal committed sons of the soil for whom the country
and its people, the poor, the downtrodden the forsaken, the deserted, the neglected, the despised, aretheir brothers and sisters. Their religion, though unique and God-given, makes no sense to our halfstarved, naked, homeless masses if it does not help them to solve their mundane problems of day-today existence. Such a practical religion deeply concerned and involved in the worldly problems of ourmasses will alone make them appreciate it and love it. We cannot give to anyone what we do not have.
Our love and concern over others, is the basic concept, by which much can be done to transform theworld. Neglect to do so in future will be at our own peril.

People can be broadly categorised under three groups: those who enjoy working with people; those
who enjoy working with things; and those who enjoy working with ideas and information. The natureof those who work with people are:
1. Caring for others, helping or serving people;
2. Persuading people or negotiating;
3. Working as a member of a team;
4. Leading or supervising others in a democratic way.
Throughout the millennia prophets, saints and sages, have implored humankind to take its responsibilities
seriously. In India for example, Mahatma Gandhi preached on the seven social sins:• Politics without principles;• Commerce without morality;• Wealth without work;• Education without character;• Science without humanity;• Pleasure without conscience;• Worship without sacrifice.
Globalisation, however has given new urgency to the teaching of Gandhi and other ethical leaders.
Violence on our television screens is now transmitted by satellites across the planet.

Conclusion
A teacher is a role model; but a bioethics teacher is a living role model. In India education for all isthe national policy and about six per cent of national net product is invested in education. We havefailed in passing onto the younger generation values that we once cherished: the spirit of sacrifice forthe motherland; the restlessness to alleviate the miseries of our poverty-stricken masses; and the urge
to build a strong India, restoring to it pride of place in the community of nations. We have failed toinculcate in them love for our cultural values based on the concept of sacrifice and service, not only to
our fellow countrymen but humanity as a whole.

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Three types of people

129

In this context, the role of education needs to be re-defined. Education should aim to integrate
physical, mental, moral and spiritual knowledge besides imparting knowledge in various disciplines. It
should strive to make a person an ideal citizen capable of shouldering the responsibilities of national
reconstruction.
As the eminent political commentator, Rajani Kothari, put it: “As we look at the situation at the endof 58 years of India’s independence, it is becoming increasingly clear that what has saved the poor
from total eclipse is not some poverty alleviation scheme launched by the bureaucracy of the planningcommission, but the poor people’s own struggles against the system, their own strategies of survivaland gradually, their own growth in confidence and sense of dignity and self-esteem”.
Out tasks ahead are to eradicate hunger and homelessness. We need to affirm our faith and commitment
to create a new India, free from social and economic bonds and backwardness. It is not a difficult task
if united we fight against class differentiation, social backwardness, gender discrimination and caste
oppression. What we need is development through social justice. An awareness of what is going on
at the national and global level should be highlighted to the students by the teachers, people by thephilanthropists and to the illiterate by well trained voluntary organisations which are not bound by thegovernment. The press can play important roles in the awareness programmes.
In the United States’ President’s Commission’s analysis, three basic principles predominated:

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1. That the well-being of people be promoted;
2. That people’s value preferences and choices be respected and;3. That people be treated equitably.
The UNESCO World Conference on Higher Education (WCHE) in Paris grappled with a number ofimportant issues such as relevance, quality, equity, international collaboration and diversification. The
Declaration for the Twenty First Century that emerged rightly spells out the missions and functions ofHigher Education.
The advancement and dissemination of knowledge through teaching and research is not the sole
purpose of Higher Education, the preservation and enhancement of cultural values is also vital. In thiscontext, the reference to the reinforcement of international understanding and the culture of peaceis quite apt. The conference also insisted that the educational institutions should at the same time beaccountable to society.
The idea of pursuing success and profit at any cost and by any means, fair or foul, during the last few
decades is inviting social disaster. If the lamp of ethical values is to be lit in the brains and hearts of the highlevel functionaries of the system, among teachers’ unions and students, and through them politicians
and the bureaucrats, there will be a reduction of substantial resources lost through malpractices thatwill then be available for the elimination of poverty, eradication of illiteracy and higher education. Soon
character building will be the sole solution for checking the desertification of the human spirit which is
responsible for the present crisis not only in India, but also in the world at large.
The education system has to be the focus point to generate and uphold education of values viz-à-vis
beneficence. This means that the weak in society also have a secure place under the sun.

References and Bibliography
Alexander, R.D. 1987. The biology of Moral System. Aldine de Greyter, New York.
Singer, P. 1981. The Expanding Circle: Ethics and Sociobiology. New York, Farror, Straus and Giroux.
Jaiswal, P.S. 1998. Ethics essential for value education. The Examiner, Oct. 30.
The Examiner, Sept. 1998, p. 9.
Yojana, Dec. 1998, pp. 14-15.

Editorial. 1998. Christian leadership for the third millennium. The Examiner, Aug. 1998, 15, p.14.
Shepphard. 1982. Basic Sociology.
Naik, J.P. 1985. Educational Planning in India.
John Macquarrie, ed. 1998. A Dictionary of Christian Ethics. London, SCM press.
New Frontiers in Education. 1998. Vol. XXVIII, No.1, Jan-Mar, p.98.
Yojana, Aug. p.48.
Kristu, J. 1996. Life-the gift and the task. Vol.12, No.3, p.50.
Thompson. 1989. Sociology for schools. Vol. I and II.

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U.S. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and
Behavioural Research. March, 1983, p. 66.

131

Bioethics: Love of life through the knowledge ofchanting for health and peace*
Chutatip Umavijani, Ph.D.
Thammasat University,
Thailand132

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Chanting is a part of sacred rituals in all religions, rituals that have become traditions and are interwoven
with religious culture in each region. At the beginning of civilisation, oral tradition was the mostimportant means of communication among people. Sound waves have been used in all parts of theworld for healing since ancient times. In Buddhism, Pali and Sanskrit have been used since Buddha’stime until now. Pali is used in the main texts of Buddhism, and also in chanting. The West also tries todiscover the secret of sounds through research and scientific methods and has found out that soundvibrations really affect man on the physical, mental, emotional and even spiritual levels.
Darryl R.J. Macer’s book Bioethics is Love of Life: An Alternative Textbook inspired me to write this paperon chanting for health and peace. Knowing what is good for us, we are much more likely to act upon it.
Having knowledge is power. Socrates said: “Virtue is knowledge.” If we have the knowledge of what isgood for us we will practice it, as all of us have “the love of life” that Macer (1998) speaks of. This paper
will elaborate upon the benefit of chanting to humankind, a sacred activity that was long practiced by
our ancestors in the distant past.
This paper tries to present the following points. First, through human love of live, we can use theeffectiveness of sound vibration in chanting to heal ourselves. Second, in studying the attributes of eachchant with its sound and power, we can clarify why each is effective. And finally we must investigate
the beginning and ending of all our actions if we want to realise the power of it. What is the essence ofwords in relation to our mind? Do our minds work like a computer that collects all the data we receive?
And how can we maintain peace through chanting?
Some of the questions that surface from this investigation are: What is the relationship between recitedwords and the human mind? Do our minds work like computers compiling and categorising all data?
If so, can the human mind protect itself from the propaganda of this capitalist society? How can we
prevent human-made and natural catastrophes from affecting our mental and consequently, ourphysical condition? Will knowing the secrets of the mind’s mechanism help us to maintain balance andorder and consequently health and peace in this ever changing, impermanent world?
In his book, “Plang Rangsi Dhamma” (The Power of Dhamma), Phra Acharn Dr. Singhon Narasapo (1999),
a revered Thai Buddhist monk, wrote of the importance of Pali sounds and how they are related to
specific organs in the body. He believes that sound vibrations stimulate the seven Chakra (the centresof pranic energy in yoga). Accordingly, certain vowels stimulate specific organs. For instance, whenthe “eeoo” sound is vocalised, the lung is stimulated; when the “aueo” sound is vocalised, the liver isstimulated and when the “chee” sound is vocalised, the lung is stimulated; when the “aueo” sound isvocalised, the liver is stimulated and when the “chee” sound is vocalised the bladder is stimulated.
In his Book on Yoga, Swami Vishnu Swami Sivananda (1995) stated that sound is a form of energy madeup of vibrations or wave lengths. Certain wave lengths have the power to heal; others are capable ofshattering glass. Mantra in Sanskrit syllables, words or phrases that are repeated in meditation, willbring the individual to a higher state of consciousness.” The word, “Om” the original mantra, popularly
used by yogis and ascetics is the root of all the world’s sounds, letters and thought. Here the “O” isgenerated deep within the body, and slowly joins with the consonant “m,” resonating through the entire
head. “Repeating Om for twenty minutes relaxes every atom in your body.” (Sivananda, 1995).

*

Paper first presented at the Second UNESCO Bangkok Bioethics Roundtable concurrent with the Eighth Asian
Bioethics Conference, March, 2007.

Dr. Richard Gerber and Dr. Andrew Weil both mention the effects of chanting and vocalising sacred words
as being magic potions for healing. As Gerber (2001) points out in Vibration Medicine, when some of hispatients who have suffered from strokes are exposed to fifteen minutes of key sound frequencies, theirbodies start to stabilise. This test has been repeated and the same results have been confirmed. Nicole
LaVoic produced sound frequency tapes called Sound Wave Energy (SWE) to harmoniously stimulate
and balance various energy levels in the human energy field (Gerber, 2001). Some of the tapes on SWE
chakra play the complex blending of fifty-two different sonic frequencies based on various biologicalelements associated with the first chakra and its related physiological functions.
In China, five musical notes form the Five Element System that comprise a pentatonic scale. They havebeen used in that country as a basis for musical composition and improvisation. Melodies with emphasison particular elements have been developed there to stimulate healing for various organs of the body
( Gerber, 2001, p.527).

The verses in each chants have different meanings and purposes. For example, the verses of many
Buddhist chants praise the Buddha as the exalted one who discovered the truth of life (Annica, Dukka,
Anatta: impermanence, suffering and non-self ). With this truth, he ultimately overcame all odds andobstacles to become enlightened. He preached the truth to those who had a little dust in their eyes.
Buddhists pay their respects to the Buddha’s great compassion, wisdom, virtue, and knowledge, Other
chanting verses praise the three essential elements in Buddhism, namely the Buddha, the Dhamma andthe Sangha.
The Mangkala Sutta containing verses that teach virtue and wisdom are recited by beginners, advanced
practitioners and those who are close to attaining enlightenment. Other suttas were composed toprovide protection from evil whether in the mind or from a danger outside. During the Buddhist Lent,
the Buddha gave the Metta Sutta to the monks as they had been disturbed by Mara, the evil spirit, as
well as other distractive forces in the forest. The Metta Sutta offers compassion and good will to all
sentient beings and thus, after chanting it, the monks were able to meditate throughout the threemonth rains retreat.
Some Parita Katha or protection verses come from the Abhidhamma of the Buddhist Scriptures. Amongthese is the Phoochangka Parita, a katha from Sudhanta Pitaka Sankyouttanikaiya which invokes theseven wisdoms that enable a person to become enlightened. During the Buddha’s time, this katha waschanted to heal those who were stricken with illness and the tradition continues in Buddhist countries
to this day. When we chant or state the truths of wisdom, it has a profound impact on the listener.
The path to wisdom and enlightenment empowers one to be filled with strength and compassion. The
supreme energy of the truth can move man and his environment.
Fugimoto Noriyuki (2004), a scientist who conducted an experiment to differentiate the energies that
affect water, observed molecules of water from different places, namely from a jar of water in front of
a computer, a pond in the vicinity of a temple and a water-filled bowl that was placed in the midst ofchanting rites. He displayed different pictures of types of atomic structures of water. The result was thatthe molecules of water in front of the computer had been distorted whereas molecules of water in abowl and in the temple pond were well formed. In Thailand, Buddhist monks pass a red thread throughtheir palms connecting it to the bowl of water as they chant blessings, an example of how the attributesof energy from water affect the human mind and body.
What connection do we have with all these sacred words? Many facets of the human mind work like a

Asia-Pacific Perspectives on Bioethics Education

Sound waves have, since ancient times, been used for healing across the globe. Western scholars andspecialists have made the attempt to unravel the secret of sound waves through research and scientificmethods. These vibration treatments are in fact related to Einstein’s theory of substance and energy
whereby man generates complex energy in dynamic equilibrium to develop the soul. Laboratory tests
show that sound vibrations affect humans physically, mentally, emotionally and spiritually. Accordingly,
a person has the ability to heal themselves if they know how to stimulate the infected organ andmaintain good health with vibrations from chanting. The root sounds originated by our ancestors are in
use to this very day and we can utilise them for healing as our forefathers have done.

133computer. Our sense perceptions receive information from all directions. When the brain compiles data,
it certainly affects our body, mind and spirit. It is our great responsibility to select the kind of data or
information we want to store. When we pronounce the truth and the virtues that accompany it, we canbecome profoundly influenced by them. Ultimately, choosing the right data is very important to ourwell being.
The world’s great religions use prayers and chanting to lead practitioners on the path to peace andhappiness. Buddhist chanting is a way to enlightenment for as the practitioner chants, he cultivates
samadhi or concentration. The chanting of meaningful words implants them in the mind. A mind thatis pure and calm has the power to focus in much the same way as the intense and penetrating beam ofa laser.
When the meditator reaches the Samadhi stage, he or she can attain a state of happiness, well being
and satisfaction in the present moment. As human beings of this century, we are subjected to a host of
temptations and catastrophe. Chanting calms the mind and puts us in a meditative state whereby wecan attain a healthy and peaceful level of mind and body.

References and Bibliography
Buddhist Chanting Book. 2003. with translation and sources. Thammasat University Press.

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Fujimoto, N. Power Energy of Water for Healing. Bangkok : Ruamtat Press, 2004.
Gerber, R. 2001. Vibrational Medicine. Vermont: Bear and Company. pp.523-5.
Macer, D.R.J. 1998. Bioethics is Love of Life: An Alternative Textbook. Christchurch, N.Z.: Eubios Ethics
Institute.
Mullin, G.H. Death and Dying: The Tibetan Tradition. Translated By Pattaraporn Sirikangana. Bangkok :Cledthai Press, 2002.
Narasapho, S. 1999. Plang Rangsi Dhamma (The Power of Dhamma), Bangkok: Loke thip Press. p.22-24.
Sivananda, Swami Vishnu Devananda. The Book of Yoga. London: Ebury Press, 1995. p. 394.
Weil, A. 1995. 8 Weeks to Optimum Health. U.S.A.: Knopf Inc.
Weil, A. 1995. Spontaneous Healing. U.S.A.: Knopf Inc.
Singhon Narasapo, The Power of Dhamma (Bangkok, 1999), Swami VishunuAn earnest appeal: We need spirituality inmedical education*
Subrata Chattopadhyay, M.D.,
Ph.D.
Maharajah’s Institute of Medical
Sciences, India

Did the physician trained in modern Western medicine gain the world and lose their soul? I asked
myself this question when I was informed that Dr. RA had been convicted of the murder of a fellow
physician in India. As I am writing this paper, RA is serving life in an Indian jail for being actively involved
in killing his medical colleague, using medical knowledge and clinical skills. I got to know RA personallyfor a number of years as we both pursued our undergraduate and postgraduate studies together in thesame two medical colleges in India. As if this was not enough to make me reflect on what the professionof medicine really means, I came to learn that Professor Dr. SM, our teacher and a reputed clinician, wasconvicted in a court of gross professional misconduct that led to the death of another doctor’s wife.
Sensational stories of gross professional misconduct, negligence, or serious apathy leading to hopelesssuffering and the loss of a patient’s life appear in the Indian media at regular intervals. While sitting at aroadside teashop near the medical college where I used to work, I heard a man comment that doctors
are just educated butchers! With no solution to the problems in sight, and even worse, no effective
system to address the grievances, this unfortunate situation escalated to the extent that Dr. V. Jaykar,a cardiologist, was shot dead outside his dispensary by a relative of his deceased patient (Pandya,
2001). Why? Because the cardiologist was strongly believed to be responsible for the death of the saidpatient!
How did we reach this horrible state of affairs? All these incidents may be the worst case scenario.
However, they nonetheless represent the eye-catching tip of the iceberg manifestations of the“inhumanity of medicine” (Weatherall, 1994). In the land that gave birth to Ayurveda and an elaborate
code of medical ethics that surpasses the Oath of Hippocrates in both “eloquence and moral idealism”(Jonsen, 2000), medicine has entered into a spiral whirlpool of erosion of values and virtues and lost its
soul. What will cure the medical maladies? Who will heal the healing profession? The appeal, therefore,
is to breathe in new life, the spirit, - to incorporate spirituality in medicine and the medical education of
tomorrow’s physicians. To understand better what it means in the present state of affairs, let us journey
down memory lane to reflect on the nature of medicine and its historical relationship with spirituality
and humanities.

Medicine: Then and now
Medicine has been known, historically and traditionally, as the art of healing. Interestingly, religion/
spirituality and medicine had common roots of origin in the conceptual framework of relationshipbetween human beings, nature, and God. In that harmonious relationship, there was no dichotomy
or any major conflict between faith and reason; rather they were complimentary to each other in the
pursuit of knowledge and patient care. Like in many other ancient societies, the priests were also thephysicians in Egyptian medicine. Ayurveda, the Hindu system of medicine, had its roots in the Rig Veda,
the most ancient body of knowledge in human civilisation, and was narrated in the Atharva Veda, thelast one of the four Vedas.
Hindu sages and monks considered knowledge in medicine as sacred, God being the ultimate source of
this knowledge of life (Bhagwati, 1997). Lord Buddha (563-477 BC) was known as a great physician in his* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005.

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Why this appeal? An introduction of a personal nature135

own times. Asoka (died 232 BC), the legendary Buddhist emperor of India, made medical care available
to both men and animals in his whole kingdom (Hughes and Keown, 1995).
Like Lord Buddha, Lord Jesus Christ was also known as the healer of both body and spirit. In the periods ofearly Christianity, religious devotees established hospitals in the Western world and played a significant
social role to provide medical care to the sick (Koenig, 2001a). Islam also significantly contributed towhat is known as modern Western medicine today (Majeed, 2005). A close relationship between religion
and medicine thus continued throughout the centuries until a chasm developed between religion andmedicine by the end of the seventeenth century (Koenig, 2001b).

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Historical events such as the persecution of Galileo (1564-1642) for supporting the Copernican viewof the universe separated religion/spirituality and medicine into two different worlds. Isaac Newton
was born in the year Galileo died. Since the time of Newton (1642-1727), scientists have accepted themodel of material universe as governed by physical laws, thus keeping faith and religious perspective
apart from science. Later, Thomas Huxley (1825-1895) championed the theory of evolution of Charles
Darwin (1809-1882) as something of a sharp contrast and opposite polarity to religious dogma (Koenig,
2001b).
The philosophy of modern Western medicine can be traced back to Rene Descartes (1596 – 1650), a
French philosopher and scientist, who put forward a mechanistic view of life (Kriel, 1989). The humanbody was understood in the conceptual framework of a working machine consisting of specificarrangement and functioning body parts. Health is the state when the machine works well; disease is thecondition when some organs/body functions go wrong and the machine cannot function or functions
less than optimally. Spectacular advances in the application of scientific method and technology inthe 20th century further isolated modern medicine from faith traditions, religion, spirituality as wellas humanities. The success of molecular and cellular biology in the recent era further reinforced themechanistic view at a more fundamental level of cells, genes and other molecules. Human life has
been thoroughly deconstructed bottom down to the cellular level where “you’re nothing but a packof neurons.” The language and method of science has spread over the whole spectrum of health andmedicine and marginalised the humanistic, philosophical or theological dimensions in knowledge
virtually to the point of exclusion.
The source of strength of modern Western medicine has also been that of a serious weakness. Medicine
concentrated attention on disease, but lost sight of the person who had the sickness. Chronic physicaldiseases, characterised by the slow dying process, occupied the spectrum of disease and death in thelate 20th century. As the relief of symptoms, not cure, is the mainstay of therapy in chronic diseases,
the notion of healing of the whole person with care for the body, mind, and spirit became more
prominent.
Furthermore, advancement in technology made health care increasingly mechanised, for example,
sustenance of life for almost an indefinite period became possible, thus blurring the distinction between
life and death. Healthcare professionals therefore became confronted with existential questions of life
(e.g. the meaning of suffering and death) that go beyond the domain of what has been known as science.
These questions of an existential nature, however, have been addressed, traditionally and historically,by religion, spirituality, philosophy and humanities. Spiritual issues at the end of life became more
important in the slow dying process of chronic physical diseases and the “biopsychosocial-spiritual”
model of care was thus felt to be the need of the hour (Sulmasy, 2002).

Medicine now – the Indian context
The ethos of medicine in contemporary India is contrary to moral values and high ideals that medicine,as a noble profession, has espoused. Modern Western medicine was introduced by British colonialists
in the first half of the 19th century (Rao, 1968). For socio-political reasons, modern Western medicine
was kept segregated from India’s indigenous or traditional systems of medicine such as Ayurveda,
Siddha or Unani-tibbi. In the era of economic liberalisation and globalisation, medicine has turned into aglamorous money-making enterprise in recent decades.

There has been an astounding 900% increase in the number of private medical colleges between 1970
and 2004 in India (Mahal and Mohanan, 2006). Medicine is neither a calling, nor a vocation any more,rather perhaps the most commercialised profession next to politics. The doctor-patient relationship,
which was characterised with trust, care and compassion, has also deteriorated into one of distrust,greed and corruption (Pandya, 2001; Pandya, 2006). Academic dishonesty in Indian medical colleges
has been known and also reported to be widespread from the top to the bottom of the establishment(Gitanjali, 2004). The situation got so bad that that the head of the Medical Council of India was removed
from his post because of corruption charges (Sharma, 2001).
The curriculum followed in Indian medical colleges has hardly undergone any significant fundamental
change since colonial times. Thus, in the land which presented the world with Eastern religions, there
is no place for religion, spirituality, philosophy, humanities, or arts in the medical curriculum. In both
Nepal and India where I have worked as a medical teacher, the importance of medical ethics and historyof medicine, although they exist in black and white as just a few lectures, are neither emphasised by
the teachers nor taken seriously by the students. For all practical reasons, the medical students havevirtually no exposure to any humanistic and philosophical knowledge during the formative years of
their medical training.

What is spirituality?
The words of religion and spirituality are often used interchangeably; they mean, however, different
things to different people. Contemporary scholars have developed a fair consensus to characterise
religion and spirituality.
The word “religion” is derived from the Latin religare, which means, “to bind together” (Gove, 1961).
Religion thus appears as “a set of beliefs, practices, and languages that characterise a community thatis searching for transcendent meaning in a particular way, generally based upon belief in a deity”(Sulmasy, 2002; Astrow et al., 2001). Religion therefore organises the collective experiences of a groupof people into a system of beliefs and practices. Religious involvement or religiosity refers to the degreeof participation in, or adherence to, the beliefs and practices of an organised religion (Mueller et al.,2001). Distinctions have been made between intrinsic and extrinsic religiosity. Intrinsic religiosity refers
to “living” a religion – practicing and believing for its own sake. Extrinsic religiosity refers to “using” areligion, that is, practicing and espousing beliefs for the sake of something else other than religious
pursuit (Mytko and Knight, 1999; Sulmasy, 2002).
The word “spirituality” is from the Latin spiritualitas, which means “breath” (Gove, 1961). Spirituality
refers to a person’s or a group’s relationship with the transcendent, however that may be construed;
and thus spirituality is about transcendent meaning in life (Astrow et al., 2001). Furthermore, spirituality
has been characterised as an experiential process whose features may include the quest for meaningand purpose, transcendence (i.e., the sense that being human is more than simple material existence),
connectedness (e.g., with others, nature or the divine) and values (e.g., love, compassion, and justice).
(Emblen, 1992; Mueller et al., 2001).
It appears that spirituality is a broader concept than religion (Astrow et al., 2001; Sulmasy, 2002). Most
institutionalised religions aim to foster spirituality, thus religiosity and spirituality are not mutually
exclusive concepts, and they can overlap and also exist separately (Mytko and Knight, 1999). Spirituality
may have group expression when it may appear as a religion, whereas intrinsic religiosity may involve asearch for meaning and purpose in life, transcendence, and connectedness with values thus appearing
as spirituality. Although everyone does not necessarily have a religion, anyone who is in the quest for
ultimate or transcendent meaning in life, could be stated to have a spirituality (Astrow et al., 2001;
Sulmasy, 2002).

Asia-Pacific Perspectives on Bioethics Education

Before we discuss the role spirituality plays in health and medicine and the importance of incorporating
it into medical education, it is essential to discern spirituality to understand better its relationship withhealth and medicine.

137Is spirituality important in medicine?
In recent years, there has been a surge in interest in understanding more about the interplay of religion,
spirituality, health, and medicine. Several books on spirituality, faith, prayer, health and healing,
authored by physicians trained in modern Western medicine, were published, and received popular
recognition (Benson, 1996; Chopra, 1998; Dossey, 1993; Matthew, 1998). A number of research articles,
commentaries and reviews on religion and health were published in major medical, behavioural
medicine and public health journals. Several academic and professional organisations including theAmerican Psychiatric Association, the American Psychological Association, the American Academy of
Family Physicians, the American College of Physicians and the Association of American Medical Colleges
stressed the need for addressing religious and spiritual issues in patient care as well as for better trainingof future health care professionals (Larimore et al., 2002). Renowned academic centres such as Harvard
and Duke University became involved in incorporating religion and spirituality into medicine. More than
80 US medical schools now offer courses on spirituality as part of their curriculum (Fortin and Barnett,
2004). Interestingly, medical students in the West are now learning more about non-Western religions,medical ethics of several faith traditions and acquiring the skills of taking the spiritual history of theirpatients.

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Whither scientific research on religion, spirituality, health andmedicine?
The dynamic relationship of religion/spirituality and health has attracted the attention of the researchers
and there has been increasing recognition and appreciation of the role that religion and spirituality canplay in health and medicine. A large number of published empirical studies have shown consistentpositive association between religious involvement and better outcomes on individual and population
health (Chatters, 2000; Koenig, 2001, Larimore et al., 2002; Mueller et al., 2001). Despite methodologicaland analytical limitations in some of these studies (Sloan et al., 1999; Sloan et al., 2000; Lawrence, 2002),
which are characteristic of an emerging field of research, the overall positive influence of religion/
spirituality on health and medicine can hardly be missed.
The association (positive, negative, or neutral) between religious commitment and mental healthstatus, as published in studies in two leading psychiatric journals from 1978 to 1989, was analysed ina 1992 report. It found that in 84 per cent of the associations (religion and mental health), religious
commitment was found to be clinically beneficial, 14 per cent were neutral, and only three per cent of
results were found harmful (Larson et al., 1992). Furthermore, between two-thirds and three-quarters ofmore than 850 studies have shown that people have better mental health and adapt more successfully
to stress if they are religious (Koenig, 2000). Not only are religious beliefs and practices associated withsignificantly lower anxiety, less depression, lower suicide rates, and less substance abuse, they are also
associated with greater well-being, hope, and optimism, more purpose and meaning in life, greater
marital satisfaction and higher social support (Koenig, 2004).
Religious involvement was also found to be beneficial in terms of physical health. Analysis of research
published in the Journal of Family Practice over a 10-year period showed a positive association between
religious commitment and health outcome in 81 per cent of the studies, a neutral relationship in 15 percent and negative in only four per cent of the studies (Craigie et al., 1990).
A large number of published clinical and epidemiological studies suggest that religious people arehealthier, live with healthier life-styles, and require fewer health services (Koenig, 2001ab; Mueller et al.,2001). Furthermore, religious involvement and practices have been found to be associated with reduced
death rates from cancer, lower rates of heart disease, emphysema, cirrhosis; lower blood pressure; lower
cholesterol, reduced rates of myocardial infarction, and increased longevity (Craigie et al., 1990; Koenig,
2001ab; Koenig, 2004; Mueller et al., 2001; Thoresen and Harris 2002).

What about patients’ spiritual needs?
Religion and spirituality are very important in the lives of many people. Many patients turn more to
religious beliefs and practices as they cope with their stressful experience during illness. Religious faithand spiritual coping have been found to be common among patients with many diseases including
asthma, chronic pain, coronary artery disease, cancer, human immunodeficiency virus (HIV) disease,renal disease, burns, and fracture (Mueller et al., 2001). Also, illness, disability, and death profoundly
affect life, thus they impose a demand to re-evaluate values and attitudes towards life, which raises
some existential questions. When a patient consults a physician to determine the cause and treatmentof an illness, he/she may also ask questions, for example: “Doctor, why did this disease happen to me?”“Why me, after all?” This is beyond the domain of modern scientific medicine. Furthermore, medicine
simply cannot ignore the broader perspective of the patient as a whole person, and thus it needs to besensitive to the religious beliefs and the emotional and spiritual needs of patients.

The link between depression, suicidal thoughts, and hopelessness has been consistently found instudies of medically and terminally-ill patients. Spiritual well-being is inversely related with depression- and addressing the emotional and spiritual needs of the patient is of paramount importance inproviding compassionate patient care. Furthermore, addressing spiritual needs in patients with diseases,
disabilities, and facing near certain death, plays a significant role in finding hope, strength and patentsatisfaction (Clark et al., 2003).

What do the patients say?
Several studies show that patients would also like their physicians to address their spiritual needs (Ehman
et al., 1999; King and Bushwick, 1994; MacLean et al., 2003; Maugans and Wadland, 1991; McCord et al.,2004). In one study with outpatients, 52 per cent believed in the right of the physician to inquire abouta patient’s religious beliefs, but a majority of the patients could not recall any physician ever having
addressed that aspect of life (Maugans and Wadland, 1991). In another study, 94 per cent of outpatientswith religious beliefs (strongly) agreed that physicians should inquire about their religious or spiritualbeliefs if they become gravely ill (Ehman et al., 1999). In a study with inpatients, 77 per cent believed thatphysicians should consider patients’ spiritual needs, 48 per cent said that they wanted their physicians
to pray with them.
However, 68 per cent said no physician had ever discussed their religious beliefs or spiritual needs (Kingand Bushwick, 1994). Furthermore, two-thirds of respondents in clinics at a multi-centre health care
centre felt that physicians should be aware of their patients’ religious and spiritual beliefs (MacLean
et al., 2003). In another survey of patients and their accompanying adults, 83 per cent of respondents
wanted physicians to inquire about spiritual beliefs in at least some circumstances. About two-thirds ofpatients believed that information concerning their spiritual beliefs would influence physicians’ ability
to encourage realistic hope, give medical advice, and also change medical treatment (McCord et al.,2004).

What do the physicians say (and do in practice)?
Many physicians also think emotional and spiritual issues are important in clinical care. In a study ofphysician preferences regarding spiritual behaviour, about 85 per cent of physicians believed theyshould be aware of the patients’ spirituality, but most would not ask about spiritual issues unless apatient were about to die. Less than one third of those physicians said they would pray with patients
if they were dying. This number increased to about 77 per cent if the physician is requested to pray.
Interestingly, family practitioners were more likely to take a spiritual history than general internists

Asia-Pacific Perspectives on Bioethics Education

If religious issues and spiritual needs are not addressed, internal struggles may result in an existential
crisis thus leading to the perception of dejection, (e.g. “God does not care for me”). The unmet spiritualstruggles take a toll on recovery and survival, including an increased risk of death, poor mental healthand low quality of life.

139

(Monroe et al., 2003). Another study found that less than 10 per cent of physicians routinely initiatedspiritual history (Chibnall and Brooks, 2001).
There are a number of reasons for this apparent discrepancy between what physicians may believe
and what they do in practice. Some physicians are not trained to take a spiritual history and addresspatients’ religious concerns and spiritual needs. Constraints of time may also be a major limiting factor.
Some physicians may also have reservations about the appropriateness of touching deeply personal
issues and some others may believe that addressing religious issues in medicine runs the risk of taking
over the role of the priest and clergy in society. From the observations made in the studies reported,
it appears that, in general, patients are positive and are in favour of physicians acknowledging andaddressing their religious issues and spiritual needs.

What do the students say?

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In one study in the US, which examined the knowledge, attitude and skills of medical students regarding
spirituality and medical practice, 81 per cent of the students agreed that the physician should consider
the spiritual well-being of the patient along with physical and mental health. Moreover, 98 per centthought that key elements in spiritual care such as empathy, understanding, compassion and listening
were also very important aspects of being a good doctor.
Eighty per cent of students believed that taking time out of their own lives was important for selfreflection, self-understanding, and spiritual growth (Anandarajah and Stumpff, 2004). An evaluation ofa brief pilot workshop on spirituality and medicine observed a modest effect in improving attitudes andperceived competence of both medical students and residents (Barnett and Fortin, 2006). It appears
that medical students are, in general, positive toward the incorporation of spirituality into medical
education.

Conclusion
Modern Western medicine has been criticised to be obsessed with the methods and language of science
with virtual elimination of other dimensions of knowledge. Medical education has been criticised forbeing a dehumanising experience. Tomorrow’s physicians need to be educated and trained in such a waythat they can take care of the physical, mental, and spiritual well-being of the patient as a whole personwith disease, rather than just conducting diagnosis and treatment of the diseases. Medicine simply
cannot ignore the real needs of patients and medical education must be sensitive and synchronouswith the noble ideals of medicine.
Spirituality plays an important role in the lives of many people, including patients. Thus, it is of utmost
importance to acknowledge and address religious issues and spiritual needs of patients with respect
and care. Incorporating spirituality into medicine may also offer unique opportunities to make positive
quality changes in the nature of medical practice in India. To offer courses on religion, spirituality, healthand medicine, as being practiced in the US medical schools, is a move in the right direction. Moreresearch is needed to understand the multidimensional and dynamic relationship of religion, spirituality
with health and medicine, upon individual and population health, at both local and regional levels.

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Perspectives on sex education*
D. S. Sheriff, M.D.
Jubilee Mission Medical College
and Research Institute, Kerala,
India.

When a child is born, the first question often asked is, “Is it a girl or a boy?” Society is organised aroundthe distinction of the sexes and our treatment of the infant from day one is influenced by the assigned
gender. Huge societal pressures, both overt and unconscious, come to bear on the child and family basedon this designation. This is not a modern 21st century phenomenon. Nearly all societies throughout
history have been captivated by the psychological and physical mysteries of reproduction and thedifferent roles of the sexes. The classical view of human sexuality holds that humans are invested witha particular sex within which they develop individually. Recent attempts to alter this concept and to
explain psychosexual maturation as developing from a neutral rather than a sexual base are topics ofcontinual discussion.
There are two theories that help to describe human sexuality. Essentially, a psychosexual neutrality-atbirth theory holds that male and female patterns of sexual orientation and behaviour are attributable
exclusively to learning or imprinting phenomena. This theory is derived from clinical observations ofindividuals manifesting morphological sexual incongruities (hermaphrodites, pseudohermaphrodites).
The other theory discusses the view of inherent somatic sexuality organising mankind’s psychosexual
development by reviewing one’s place on the evolutionary continuum, and the broad base of sexual
behaviour. These theories try to help us understand the genesis of human sexuality. What we witness
today is the need to impart a true life value education to our youngsters that human sexuality is much
more than an instinct and has various domains like biological, physiological, genetic, sociological,
cultural and traditional values. In this paper an attempt is made to understand sex education in its
totality.
Sex education is the process of acquiring information and forming attitudes and beliefs about sex,
sexual identity, relationships and intimacy. It is also about developing young people’s skills so thatthey make informed choices about their behaviour and feel confident and competent about acting
on these choices. It is widely accepted that young people have a right to sex education, partly because
it is a means by which they are helped to protect themselves against abuse, exploitation, unintended
pregnancy, sexually transmitted diseases and HIV/AIDS.
It must help to reduce the risks of potentially negative outcomes from sexual behaviour like unwantedor unplanned pregnancies and infection with sexually transmitted diseases, and to enhance the qualityof relationships. It may help develop young people’s ability to make decisions over their entire lifetime.
Effective sex education is sex education that contributes to this overall aim.
For sex education to be effective it needs to include opportunities for young people to develop skills,
as it can be hard for them to act on the basis of only having information. Skills such as being able
to communicate, listen, negotiate, ask for and identify sources of help and advice, are useful lifeskills and can be applied in terms of sexual relationships. It may help develop young people’s skills
in negotiation, decision-making, assertion and listening. Other important skills include being able torecognise pressures from other people and to resist them, deal with and challenge prejudice, seeking
help from adults, including parents, carers and professionals, through the family, community and healthand welfare services.
It is important that these skills equip young people to be able to differentiate between accurate and* Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005.

Asia-Pacific Perspectives on Bioethics Education

Introduction143inaccurate information, discuss a range of moral and social issues and perspectives on sex and sexuality,
including different cultural attitudes and sensitive issues like sexuality, abortion and contraception.
Young people are exposed to a wide range of contradicting and confusing attitudes and beliefs inrelation to sex and sexuality. For example, some health messages emphasise the risks and dangers
associated with sexual activity while some media coverage promotes the idea that being sexually active
makes a person more attractive and mature.
Young people are very interested in the moral and cultural frameworks that bind sex and sexuality. They
often welcome opportunities to talk about issues where people have strong views, such as abortion, sex
before marriage, lesbian and gay issues and contraception and birth control. It is important to rememberthat talking in a balanced way about differences in opinion does not promote one set of views overanother, nor does it mean that one agrees with a particular view. Part of exploring and understanding
cultural, religious and moral views is finding out that you can agree to disagree.

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Individual attitudes and beliefs of sex educators about sex and sexuality must not influence negatively
on the sex education that they provide. For example, even if a person believes that young people should
not have sex until they are married, this does not imply withholding important information about safer
sex and contraception. Imposing narrow moralistic views about sex and sexuality on young people
through sex education has failed. Moral deterrents and frightening young people away from having
sex will not supplement effective sex education. It may include work on attitudes and beliefs, coupledwith skills and development that enables young people to choose whether or not to have a sexual
relationship by taking into account the potential risks of any sexual activity.
It may provide young people with an opportunity to explore the reasons why people have sex, and to
think about how it involves emotions, respect for one self and other people and their feelings, decisions
and bodies. It may give them the chance to explore gender differences and how ethnicity and sexuality
can influence people’s feelings and options. It must allow them be able to decide for themselves what
the positive qualities of relationships are, as opposed to negative ones such as bullying, stereotyping,abuse and exploitation.
Information about sex and sexuality are available from a wide range of sources including the media:
advertising, television and magazines, as well as leaflets, books and websites. Sex education therefore
provides additional information to add to the individual’s existing knowledge, and helps to correct any
misinformation they may have.
Information regarding physiological, psychological and patho-physiological aspects of the following
topics need to be given:• Sexual development;• Reproduction;• Contraception;• Relationships.
In terms of information about relationships people need to know about what kinds of relationships there
are, about love and commitment, marriage and partnership and the law relating to sexual behaviour
and relationships as well as the range of religious and cultural views on sex and sexuality and sexual
diversity.
Before young people reach puberty, and develop established patterns of behaviour sex education may
be provided. Providing basic information helps to establish the foundation on which more complex
knowledge is built up over time. This also means that sex education has to be sustained. For example,
when they are very young, children can be informed about how people grow and change over time,and how babies become children and then adults, and this provides the basis on which they understandmore detailed information about puberty provided in the pre-teenage years. When they are young they
can also be provided with information about viruses and germs that attack the body. This provides thebasis for talking to them later about infections that can be caught through sexual contact.

It is an important responsibility to talk openly with children about sex and sexuality, this contributes togreater cultural openness about sex and sexuality and improved sexual health among young people.
Different settings provide different contexts and opportunities for sex education. At home, young people
can easily have one-to-one discussions with parents or carers which focus on specific issues, questions
or concerns. They can have a dialogue about their attitudes and views. Sex education at home also
tends to take place over a long time and involve lots of short interaction between parents and children.
There may be times when young people seem reluctant to talk, but it is important not to interpret any
difference as meaning that there is nothing left to talk about. As young people get older, advantage
can be taken of opportunities provided by things seen on television, for example, as an opportunity toinitiate conversation. It is also important not to defer dealing with a question or issue for too long as it
can suggest that you are unwilling to talk about it.
School-based sex education will include formal programmes with the following elements:

School-based education programmes are particularly good at providing information and opportunities
for skills development and attitude clarification in more formal ways through offering lessons within acurriculum. Community based projects provide opportunities for young people to access advice andinformation in less formal ways. Sexual health and other health and welfare services can provide accessto specific information, support and advice. Sex education through the mass media, often supported by
local, regional or national government and non-governmental agencies and departments, can help toraise public awareness of sex health issues.
There are cross-cultural and political differences in adopting a unified approach to the teaching of
education for the creation of healthy society. Sex education therefore needs to be imparted taking into
consideration that it does not clash with regional, religious or cultural values. Love and care, caution andprevention, and a positive approach to life will therefore mould and shape the destinies of our younger
generation. Life values embedded education will create a healthy environment to face and fight thethreat of AIDS and make our region a haven of young minds fine-tuned to a healthy family life.

References and Bibliography
Sheriff, D.S. 1983. Adolescent sexuality: a worldwide concern. Postgraduate Medicine, Vol. 74, No. 3, p.
61.
Wight, D., Abraham, C. and Scott, S. 1998. Towards a psychosocial theoretical framework for sexual
health promotion. Health Education Research, Vol. 13, pp.317-330.
Kirby, D., Barth, R., Leland, N. and Fetro, J. 1991. Reducing the risk: a new curriculum to prevent sexual
risk-taking, Family Planning Perspectives, Vol. 23, pp. 253-263.
“National Guidelines Task Force (SIECUS). 2004. Guidelines for Comprehensive Sexuality Education:
Kindergarten through 12th Grade, New York: Sexuality Information and Education Council of the UnitedStates (SIECUS) (Accessed 3 July, 2005).
Meyrick, J. and Swann, C. 1998. Reducing the rate of teenage conceptions an overview of effectiveness ofinterventions and programmes aimed at reducing unintended conceptions in young people. London: Health
Education Authority.

Asia-Pacific Perspectives on Bioethics Education• A focus on the meaning of sex education;• How to prepare to avoid risky sexual behaviour and make it habitual;• Theories to explain the influences of people’s sexual choices and behaviour;• Providing accurate information about the risks associated with sexual activity, contraception and birthcontrol, and methods of avoiding or deferring intercourse;• Dealing with peer (and other) social pressures on young people;• Providing opportunities to practice communication, negotiation and assertion skills.

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Sheriff, D.S. 2000. Understanding Human Sexuality.
Wellings, K., Wadsworth, J., Johnson, A.M., Field, J. and Whitaker, L.B. 1995. Provision of sex educationand early sexual experience: the relation examined, British Medical Journal, Vol. 311, pp. 417-420.
Kirby, D. 2001. Emerging answers: research findings on programs to reduce unwanted teenage pregnancy.
Washington, DC, USA: National Campaign to Prevent Teen Pregnancy, (Accessed 3 July, 2005).
Ingham, R. and Van Zessen, G. 1998. From cultural contexts to interactional competencies, paper at AIDS in
Europe: Social and Behavioral Dimensions Conference, Paris, 12-16th January.
Teenage Pregnancy Unit. 2002. Teenage Pregnancy Unit Involving parents in prevention: resource - involving
parents. London: Teenage Pregnancy Unit, accessed 2nd July 2005.
Blekinsop, S., Wade, P., Benton, T., Gnaldi, M. and Schagen, S. 2004. Evaluation of the APAUSE Sex andRelationships Education Programme, London: National Foundation for Educational Research (Accessed
7 July, 2005).

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Stephenson, J.M., Strange, V., Forrest, S., Oakley, A., Copas, A., Allen, E., Babiker, A., Black, S., Ali, M.,
Monteiro, H., Johnson, A.M., and the RIPPLE study team. 2004. Pupil-led sex education in England (RIPPLE
study): cluster-randomised intervention trial, The Lancet, Vol. 364, No. 9421, pp. 338-346.

Toward Successful Bioethics Education*
Atsushi Asai, MD, MBioeth., PhD.
And Miki Tanoue, RN, Med
Kumamoto University,
Japan

Introduction

However, compared to the degree of progress and extent of the improvement of pre-and post-graduate
bioethics education, the changes in medical practice still remain unsubstantial from a bioethicalperspective. In other words, bioethics education for healthcare practitioners has yet to produce sufficientresults. Despite regional differences, there are many places where the practice of healthcare remains
unchanged by the current ethical milieu. With this in mind, this paper delineates and discusses reasons
why pre- and post-graduate bioethics education for healthcare practitioners is unable to produce
practical results. We believe the study of bioethics has to be pragmatic. Bioethical issues should be
resolved where medicine is practiced and healthcare practitioners should embody the appropriate
characteristics that promote ethical decision-making. We would like to consider how this can be madepossible.

Pre-and post-graduate bioethics education for healthcare
practitioners does not yield sufficient results for five reasons:
1) Lack of training opportunities
Compared to a decade ago, the numbers of hours and opportunities for pre-graduate bioethics
education have certainly increased. However, we are compelled to believe that this is insufficient fora systematic and comprehensive approach to bioethics education. The number of classroom hours
currently allotted are in no way sufficient for introducing detailed example cases, discussing papers,
and holding meaningful class discussions and presentations. Based on our experience, it takes at least
90 minutes to discuss a single case entailing an ethical issue. Discussing a paper requires a full lecture
period, and several hours are needed to fully examine a single issue.
Opportunities for post-graduate ethics education are lacking entirely. It is especially difficult for medical
professionals such as physicians and nurses to set aside time to discuss example cases. The opportunities
for bioethics instruction that some facilities provide to their staff are offered at most once, or twice ayear, and most facilities do not provide them at all. In many cases, the only staff members that receive
training in bioethics are new interns or nurses.
The primary cause for this situation might be that the responsible party does not understand theimportance of bioethics, the priority for which is set lower than many other subjects, despite the factthat the importance of ethics in medical fields has been emphasised socially. Some universities andinstitutions may provide bioethics education only as a formality so as not to degrade their external
evaluations because the absence of bioethics education for medical researchers and practitioners can*Paper first presented at the joint UNESCO:UNU-IAS Roundtable on Japanese Perspectives on Bioethics Education
held in Yokohama, Japan in February, 2007.

Asia-Pacific Perspectives on Bioethics Education

The ultimate goal of pre-and post-graduate bioethics education for healthcare practitioners (healthcare
students and professionals) is good medical practice. To this end, it is vital to educate “healthcare
practitioners to be ethical.” By “ethical” we mean an individual with an honourable personality and theability to make appropriate decisions. Compared to a decade ago, the bioethics education of medical
students in Japan improved in terms of quality and quantity, and there is now a greater awarenessof bioethical issues at healthcare facilities than in the past. Furthermore, with the exception of someparticular cases, the demeanour of medical professionals, especially that of physicians, has generally
improved.

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negatively impact evaluations of medical institutions.
2) Problems with quality (content)
By whom? For whom? What? When? For what purpose? And how? The way pre-and post-graduate
bioethics education for healthcare practitioners is implemented are important questions, the answers
to which have yet to be determined. The means by which bioethical issues are integrated into theclassroom could vary. For example, there may be instructors who, concerned with bioethics as it ispracticed in the United States, give no consideration to Japanese bioethical perspectives. It is possiblethat a medical school professor who has no expertise in bioethics merely expresses their personal moral
views in the classroom, uncritically believing that it is good bioethics education. Depending on thevarious curriculums followed by the institution, it is possible that only first-year students may have an
opportunity to receive an education in bioethics. Some instructors may only address social issues thatare the subject of their own interests. At present, the actual state of bioethics training during postgraduate education is not well understood.

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Of greatest importance is the sense of purpose and pedagogical approach of bioethics instructors
provide as it relates to their subject of expertise. Do they regard bioethics education merely as a formof cultivation; or do they consider it as an opportunity for them to impart knowledge, a means forsocial change, or an educational opportunity for their students to develop character? What and how
information is presented and what sort of discussions and conclusions students are instructed in will
differ greatly based on an educator’s awareness of the problem.
Certainly when the purpose of bioethics education is understood as the offering of knowledge and theacquisition of ethical reasoning methods, it is possible to overlook whether or not a student came to aconclusion on their own and what kind of conclusion they reached. The way an instructor’s performance isevaluated (class evaluation) is different depending on the established purpose of bioethics education.
How should educators conduct themselves in front of students of healthcare-related professions if theycannot accept contemporaneous ethical guidelines, regulations, commonly accepted norms, publicorder and morals? And how should they talk about ethical matters for which a uniform opinion has
not been established (issues involving conflicting opinions)? Such important questions have yet to beresolved.
3) How to evaluate students
By what criteria we should evaluate students is also a major issue. Should we check their knowledgeof bioethics, measure their receptivity to bioethical issues using an existing scale, or evaluate theirargumentative ability by having them write an essay? Should we pass or fail them based on whether
or not they have a certain ethical attitude? Evaluation methods must be closely related to bioethics
educational goals, but a suitable evaluation method cannot be determined where there is no consensus
on the goals of bioethics education.
Whether or not multiple-choice questions measure anything other than a student’s memory isquestionable. At the very least, they do not measure a student’s sensibility, reasoning ability, orconversation skills. Even if the established goal of bioethics education is to “make students more ethical”
as we emphasise, a tool to correctly measure their “ethical degree” might not exist.
4) The self-termination of bioethics education
If we consider making a student “ethical” to be the purpose of an effective education, then in our
opinion, successful results are especially important for the bioethics education of pre-and post-graduate
healthcare practitioners to be perpetually effective outside of the classroom. However, it remains amatter of concern that bioethics education is limited to the classroom and ends there. In most cases, thisends merely in satisfying the complacency of the instructor and student. It does not result in realistic
criticism of the current situation, and does not lead to a change in performance in the workplace later
on. Only a superficial knowledge remains and as time passes, most of this learning will be lost. Even if

a student’s education is stored as knowledge, or as a way of thinking, these views and values are notexchanged with others in conventional conversations.
As the proverb goes, “Only when a man can afford food and clothing will he understand etiquette”; andpressure from the workplace deprives individuals of the time and psychological energy to spare fortaking a moment to think or engage in discussion. It is possible that the roles of ethics committees are
viewed as an unfair and unnecessary intervention to the discretion of healthcare professionals and thedoctor-patient relationship. There are many senior physicians who have an aversion even to hearing theword ethics. There may even be some healthcare professionals who regard themselves as a paragon of
ethics, unreceptive to viewpoints that differ from their own. When such people are their own boss, it islikely that the ethical perspectives of novice healthcare professionals may be compromised.

Some may feel discomfort and fear that they will be criticised by their colleagues and superiors if theyexpress their own ethical perspectives. The “follow-the-crowd” mentality and unassertiveness often
observed among Japanese people, the tendency to eschew free thinking and discussion for individuals,
hierarchy and conventionalism at the workplace, formal education that does not place value on voluntarystatements, and, furthermore, the deficiency of practical medical ethics training in medical educational
institutions might be the remote causes for this. For the Japanese, stating ethical convictions may be
the same as unguardedly revealing yourself as a “potential adversary.”5) What does “being ethical” mean?
In the beginning, we said that “being ethical” is having an honourable personality and the ability tomake appropriate decisions. However, we know this kind of definition will incite antipathy and a large
number of questions, because it is unclear as to what kind of personality is honourable and what kindsof decisions are appropriate. The fundamental question remains concerning what kind of decisions are
good, and how we define what it means to “be good.”
Looking back on the history of bioethics, there are no ethical issues that have reached an ethicalconclusion free of objections. A strong premise to persuade individuals with an ethical judgment has
yet to be found. Occasionally, either public guidelines or current law is mistakenly taken as “ethicallycorrect” and not given due consideration.
There are some medical practitioners who cannot differentiate between substantial justice andprocedural justice since they claim that the only thing needed to resolve ethical problems are appropriate
procedures. Freeman also argues that some ethicists turn from the important issue of what to do, tothe issue of whom to ask, to who should decide, as if that were a substitute for what should be decided(Freeman, 2006).
Character guidance and moral education might not be possible. If possible, they could lead tobrainwashing or indoctrination. Universally acceptable character traits may not exist, but if they did,opinions would be especially divided over what kinds of decisions those traits should marshal in certain
cases. On the other hand, the list of desirable character traits is clearly defined in professionalism
education for medical practitioners, which is attracting more attention. Citing many examples,
Darryl Macer (2007) persuasively suggests that personal moral development is one goal of bioethics
education. Realistically, few people would think it no problem that medical practitioners are unethicalor disagreeable. Thus, there currently exists no consensus on character guidance.

Asia-Pacific Perspectives on Bioethics Education

Midway through a bioethics education, all participants are expected to discuss ethics. However,few healthcare practitioners voluntarily join open-participation study groups, and the number ofphysicians attending such groups is especially low. Furthermore, individuals who voluntarily initiate
ethical discussions are perhaps rare. Presumably, Japanese people are traditionally burdened with thetrilemma of “won’t speak,” “won’t decide,” and “won’t think” when it comes to ethical issues. They feela strong psychological resistance to ethical discussions, and vigorous discussions are not generated
equally with others.

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Toward the establishment of bioethics education that strikes a chordwith students

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Asia-Pacific Perspectives on Bioethics Education

In the aforementioned sections we delineated several points that we believe are detrimental to effective
bioethics education and to making healthcare practitioners ethical. It is necessary to have the numberof hours of education increased, continue to explain the necessity of bioethics education for healthcare
practitioners, and examine and understand the present state of bioethics education. Furthermore, as
researchers, educators must also be committed to working on the resolution of normative ethics andmeta-ethical issues. However, when a student’s education ends, so too does evaluation; but how cantheir education continually demonstrate their effectiveness after a student enters the workplace as ahealthcare practitioner?
Unfortunately, no breakthrough plan exists. However, in order to produce results that lead to healthcare
practitioners becoming ethical, we feel that the values of a bioethics being imparted to students is more
important than anything else and that bioethics education need strike a chord with students. Mereknowledge, reasoning techniques, and ability to analyse papers are not enough. It is necessary that
ethical matters examined and talked about at the pre-and post-graduate stages stimulate a student’s
passions and from time to time arouse a deep resonance that can lead to action by sympathising withcertain thoughts and behaviour. It should not be some kind of “tear-milking” education that appeals
only to the emotions, but instructors with nihilistic demeanours are also unfavourable. Coercive moral
teachings and “sermons” will not do, as students will close their minds to such instruction from the very
beginning. An instructor with some degree of normative beliefs is called for. An extremely delicate
balance is required.
Ordinary students are not impressed by philosophical texts and bioethics textbooks. Educational
materials need to stimulate a student’s five senses as much as possible; and supplemental materials
that get students to think after seeing, hearing, and feeling them are also desired. This is the case forworks of literature, films, and nonfiction commentaries. However, propaganda-like materials that
promote a particular standpoint too much must be avoided. Educational materials are needed thatare emotional and intellectual, but able to stand up to critical appreciation. More than anything else,
education that gets students to think naturally is desired. Emotions devoid of intellectual interests are
only temporary.
Making opportunities to discuss with others from diverse backgrounds—such as students of nursing,
medicine, and/or healthcare fields at the university level—is especially important. It is expected that a
student’s aversion to ethical discussion will decline as they become accustomed to talking about ethicalissues. Once ethical thought comes to a conclusion in one’s mind, it is often stifled and the opportunity
to improve individual thought by exchanging opinions with others is lost. Education in communicationis required at this time so that students will sympathetically and composedly listen to what others haveto say, and be able to express their own opinions with consideration to other people’s feelings. Of
course, for students to just speak with others is not an adequate form of education; academic lecturesby instructors and opportunities to become familiar with textbooks and papers are also necessary.
To summarise, to better foster ethical student healthcare practitioners, presenting issues anddiscussions that use intellectually and emotionally stimulating, balanced, impressionable materials
and opportunities for productive exchange of opinions is necessary. Bioethics education is needed thatstrikes a chord with students. We must continue our efforts in the pursuit of an ideal education.

References
Freeman, J.M. 2006. Ethical theory and medical ethics: a personal perspective. Journal of Medical Ethics,
Vol. 32, pp.617-8.
Macer, D.R.J. Goals of Bioethics Education and the Asia-Pacific Action Plan. Presentation at UNESCO-UNU
Bioethics Round table, 15-16 Feb. 2007, Yokohama, Japan.

Changes in bioethics education in Japan, with special
comments on medical ethics education in Japan
during World War II*
Shinryo N. Shinagawa, M.D.
Hirosaki University School of
Medicine, Japan

Bioethics education was started in Japanese medical schools in the 1980s, and then it spread rapidly
spread to nursing schools, law schools, etc. Up to the 1970s traditional medical ethics was taught
in Japanese medical schools, usually based on the Hippocratic Oath and Encheridon Medicum (by aGerman medical philosopher Christoph Wilhelm Hufeland, 1762-1836).
Because in the early 1980s there were so few bioethics specialists in Japanese medical, nursing, andlaw schools and universities, the media played a great role as quasi-educators and/or stimulators ofbioethics, announcing domestic and foreign hot news. Besides the media, a great number of nonmedical specialists have played a major role in bioethics education and discussions since the 1980s
in Japan. These people are principally lawyers, religious leaders and university professors of ethics,
sociology, philosophy, and other related subjects.
Specialisation is progressing in bioethics today. Many bioethicists are discussing topics such as humanrights, informed choice or consent, euthanasia, organ donation, DNA and genes, for example. At thesame time, the others have had a great interest in environmental issues, overpopulation, natural
resources, nuclear issues and global warming. Furthermore, many are discussing metabioethics. Whereis bioethics going? What should be taught and discussed on bioethics in schools? Everything is always
changing and moving, and nothing stops.
A new style medical education is necessary. Medical ethics education should not just involve leading
staff such as deans of medical schools and key personnel in hospitals. More people need to get involved.
At the same time, new style medical textbooks should be published. Traditional descriptions in medical
textbooks are almost limited to etiology, symptomatology, diagnostics, therapy and treatment,
prognosis and clinical statistics. Almost nothing is described and discussed regarding ethical, legal andsocio-economical issues. This is the main reason why new style medical textbooks are necessary.

Medical ethics education I received during World War II
I would like to share my own experiences of medical ethics education for historical interest. During WorldWar II, I received a medical education at the Tohoku Imperial University in Sendai, which is now called
Tohoku University. I graduated to become a physician. At that time, far more people were suffering fromtuberculosis and other infectious diseases and there were no such technologies as in-vitro fertilisation ororgan transplantation. No particular attention was paid to informed consent or human rights. Regarding
ethics for those engaged in the field of medicine, we were taught about the duties of doctors.
We were taught in detail the Hippocratic Oath and Enchiridion Medicum by C.W. Hufeland. As a matter*

Paper first presented at the joint UNESCO:UNU-IAS Roundtable on Japanese Perspectives on Bioethics Education
held in Yokohama, Japan in February, 2007.

Asia-Pacific Perspectives on Bioethics Education

Based on my own experience as a medical student during World War II, and as a medical practitionerof around 60 years, this paper includes a few comments on bioethics and medical ethics education in
Japan, with special attention to my experiences during World War II. “Bioethics” was introduced to Japanin the 1970s from the United States and has been popularised rapidly since the 1980s, triggered by aseries of discussions on induced abortion, brain death/organ transplant, in vitro fertilization/embryotransfer, euthanasia and so on.

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of fact, Hufeland’s book on doctors and ethics was translated from German to Dutch and the Dutch
version was brought to Japan during the Edo period. So, back in 1838, the Japanese version was readily
available in Japan.
Hufeland particularly valued and emphasised not only the duties of doctors in general, but also theduties of doctors to the sick and the duties of doctors each other. Up to this point, bioethics education
had not changed so much. Let me now talk about some things that were emphasised during the war
but are seemingly barely taught today.

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First of all, we were taught how we physicians should deal with patients with infectious diseases. We
were taught that it was unavoidable to isolate such patients, giving them various restrictions and evenviolating their human rights. Patients suffering from acute infectious diseases, such as dysentery, as wellas leprosy patients were the ones who had to be the most strictly regulated and isolated. Tuberculosis
patients, particularly those who discharged tubercle bacilli in their sputum, were also strictly handled.
Rumours were widespread that leprosy patients were forced to undergo sterilisation operations andinduced abortions, and this turned out to be true after the end of the war.
The second thing we learned was the fact that the job of a military doctor would be different from a
doctor employed in a medical practice for the general public in various ways. Suppose, for example, you
are in charge of physical examinations for conscripted soldiers and there are 10 equally healthy young
men in front of you, and you must pick five and send them for military induction. The professor asked
us what principles we would use to select the five. Among the 10 might be the son of a poor tenant
farmer who works hard to support his household on the one hand and a landowner’s son who is always
fooling around on the other hand. Someone may be the only son in the family, while the other potential
conscript may be the youngest one of seven brothers. Whereas one may be unable to read or write, theother may have graduated from college. “Now, how would you choose five out of 10?” the professor
asked us at the end.
Then, suppose you are finally at the front line in the war. With the conflict intensifying, the number ofcasualties is so large that a team of only one doctor and two medical orderlies is unable to take care of
all the injured. Some soldiers look more dead than alive, and it seems impossible to save them. On theother hand, some seem to have the chance of survival with immediate treatment while others havesustained minor injuries. The professor, then, asked us how we would deal with these people, whether
we would put priority on the soldiers in the higher ranks, leaving those in lower ranks to succumb totheir injuries, or should we adopt some other method of choice. His answer was to start treating those
who appeared to have a chance of survival and leave those with minor injuries behind. In this way, welearned a variety of things students nowadays are not usually taught in bioethics education.
Apart from the things mentioned above, we may have been taught about the International Red Cross
principle to bring assistance without discrimination to the wounded on the battlefield. But it somehow
does not remain so clear in my memory. On the contrary, stories like how harshly the American soldiers
handled injured Japanese soldiers in Guadalcanal and other places were circulated among students.
However, we were actually taught something more awful and what was not supposed to exist.
According to what we’ve heard, the primary task of army doctors is to see through feigned illness: A
soldier complaining that he can no longer walk even though he should be able to; a patient who always
has a fever when his temperature is taken, though he appears to be able to leave hospital; a soldier
yelling that his legs ache so much when they are touched a little, saying that he cannot march. “To see
through whether they are deliberate or real, it is the military doctors’ biggest task,” a teacher told us.
Furthermore, one of my seniors whispered to me and this is what I would like most to emphasise what
he said. “In the world where we live, there are so many more places that are far more awful and dreadfulthan the army. In these places, completely different ethics and morals go on openly, and there areprisons and sanitariums, particularly those for leprosy patients,” he said. He said these places were almost
completely isolated from the outside world, which was then often referred to as shaba in Japanese, andinmates of these facilities were not allowed to go out even on Sundays and national holidays.
Quite recently, I read an article on slackers in the German weekly magazine Der Spiegel (Page 56, 11th

Asia-Pacific Perspectives on Bioethics Education

issue, 2007). According to the story, an increasing number of malingerers (who are called Drueckeberger
in German) who evade military service (an act called Ausmusterung in German) have surfaced as aserious problem in that country. But I will not go into details. Perhaps things do not change so much,
but we still need ethics.

153Current status of ethics education at agricultural
universities in Japan
Atsushi Tajima, Hiroshi, Hiki,
Mutsumi Itoh, Tomonari
Yamamoto, Momoyo Itoh, Mizuki
Matsuoka, Tsuyoshi Homma,
Keiko Tomita
University of Tsukuba, Japan

Introduction: Why ethics in agriculture?

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Asia-Pacific Perspectives on Bioethics Education

According to “The Report of the Panel of Eminent Experts on Ethics in Food and Agriculture” by theUnited Nations Food and Agricultural Organization (FAO), the most urgent ethical task in agriculture is
described as “to assess activities relating to food and agriculture in the light of their actual and potential
impact on the reduction of poverty, hunger and malnutrition” (FAO 2001a).
Since then, the FAO has published a series of publications on ethics in food agriculture arguing various
topics including genetically modified organisms, sustainable agriculture, and fisheries (FAO 2001b, FAO
2001c, FAO 2004, FAO 2005). The background of the argument is based on the recognition that theaccessibility to the quality of food is deeply related to the human rights issue. However, issues related tothe accessibility to quality of food are diverse and complicated in nature (Macer et al., 2003).
The coordination of government and public sectors is essential to address this important agenda. Under
these circumstances, the higher education system needs to play a central role in conducting researchand education on ethical issues in agriculture. Japan is not an exception from the issues and the higher
education system in agriculture has been playing important roles in improving food productivity.
When we look back, the major historical events that occurred in Japan in the area of agricultural
education over the past 150 years, the education system in Japan experienced two major reforms:
1) after the Meiji restoration in 1868, when the Tokugawa government fell because of heavy politicalpressure, and the power of Emperor Meiji was restored. 2) After the end of the World War II in 1945. It isquite ironic that the westernisation of Japan was started at the Meiji restoration in 1868, and the speedof westernisation was even enforced after World War II. There is no question that the education system
in Japan was greatly influenced by these two historical events.
In May 1991, the Standards for the Establishment of Universities were amended. And in April 2004, all
the national universities were reorganised as a national university corporation. It was very fortunatethat we launched a project in 1987 at the Agricultural and Forestry Research Centre at the University ofTsukuba to compile all the agricultural courses offered at agricultural universities in Japan. This covers
the data since 1983 and was entered into a newly created database called “AgBase”. We are now able
to monitor the changes before and after the amendment of the Standards for the Establishment of
Universities using “AgBase”. In the present manuscript, we will first overview the historical developmentof the agricultural programme at universities in Japan and describe the current situation of bioethics
education afterwards.

Historical development of agricultural education at universities inJapanAccording to Nagai (1965), the Japanese university system could be divided into three periods. The first
period was from the Meiji era to the early Taisho era (1868-1918). The second period was from 1918 tothe end of World War II (1945) and the third period was from the end of World War II to 1965, the time of
Nagai’s report (but which, for the purposes of this paper, has been extended to 1991). Although social*

Paper first presented at the joint UNESCO:UNU-IAS Roundtable on Japanese Perspectives on Bioethics Education
held in Yokohama, Japan in February, 2007.

conditions around Japan varied greatly during these periods, improvements in agricultural production
was always seen as a national imperative.

First Period (1868-1918)
The first period began with the Meiji Restoration in 1868. The Meiji Government recognised that Japan’sscientific and technological development lagged behind that of the United States and Europe and theadministration implemented measures to turn Japan into a major industrial nation. Naturally, this hada significant effect on the educational system. From the outset (1886), Tokyo Imperial University, thefirst university in Japan, offered traditional academic programmes in its colleges of law, liberal arts, andsciences, as well as programmes in applied fields such as engineering.

Of these 259 natural science students, 87 were studying engineering, 85 studying medicine, and 17
were studying agricultural science, in contrast to the 53 students in basic sciences, clearly indicating
the emphasis on applied fields. It should also be mentioned that the major role of all the campusesof Tokyo Imperial University, i.e., the colleges of law, humanities and science, was to translate andintroduce technical papers, originally written in English or other European languages, into Japanese.
This means that Japanese universities started not as institutions pursuing purely academic interests, but
as institutions which sought to acquire and diffuse practical knowledge from technologically advanced
Europe as well as USA. In the over 100 years which have elapsed since then, this fundamental trend
toward emphasising applications over purely academic pursuits has remained strong in Japanese
academia.
The establishment of Sapporo Agricultural College and Komaba Agricultural schools
There are basically two schools of agricultural education, one originating from the Sapporo Agricultural
College (SAC) (presently the Department of Agriculture and the Department of Veterinary Medicine of
Hokkaido University) and the other based at Komaba Agricultural School (presently the Department ofAgriculture of the University of Tokyo). Therefore, a brief examination will be made on the backgrounds
under which each school was established and the distinguishing features of their respective methodsof instruction.
Sapporo Agricultural College (SAC)
During the early Meiji Era (that is 1870s or thereabouts), most of Hokkaido, with the exception of coastal
areas and the southern districts, was undeveloped. The development and settlement of this island
therefore became a major concern of the government. In particular, since the late Edo period, trouble
had often occurred with Russia, which was seeking to expand southwards. Therefore, the clearing ofland and settlement with Japanese nationals was not merely to promote development, it also becamea key focus of diplomacy issues. Given this situation, the Kaitakushi (“Bureau of Development”) was
created in 1869 to intensively pursue the development of Hokkaido under the very strong leadership ofthe director of the bureau, Kiyotaka Kuroda.
Without his farsighted strategy, the development of Hokkaido would have been very much different.
Many technicians, primarily from the USA, such as Horace Capron were employed at the Bureau, whichsought to draw on the technical know-how and experiences of Europe and America for this endeavour.
To foster the development of talented individuals in Japan, the Bureau established the Kaitakushi-karigakko (“Temporary School of Development”) in Tokyo in 1872. One of the requisites of this new school
was to establish technical schools in Hokkaido in the future, which was later referred to as Sapporo

Asia-Pacific Perspectives on Bioethics Education

During this period, the Japanese government invited numerous foreign professors to teach at Japanese
universities; in 1873, for example, the government allocated 14 per cent of its educational budget topay foreign professors, and 18 per cent of this budget to pay Japanese nationals to study at universities
outside Japan. During the 34 years from 1875 to 1908, the Japanese government was clearly stressing
the importance of natural sciences, sponsoring 259 Japanese nationals to study natural sciences atforeign universities, in contrast to the 114 social science students, 42 students of humanities, and 15 art
majors who were sent overseas.

155

Agricultural College (SAC).
Under a recommendation by Kiyotaka Kuroda, the director of Kaitakushi, the Japanese government
signed a one-year contract with William Smith Clark (1826-1886), the then-president of Massachusetts
Agricultural College (MAC), in Washington, D.C., on March 3, 1876. Under the terms of the contract, theJapanese government was to employ Clark as vice-chancellor, as well as an instructor in agriculture,chemistry, and English. The MAC curricula included not only technical education in agriculture, butalso sought a holistic instruction including ethical and physical education. Clark incorporated theconcepts of MAC’s curricula in the formation of the curricula of SAC, which therefore became extremely
distinguished. Specifically, the relative importance of English as a language increased; subjects related
to speech-making and debate skills were offered, as well as a multi-disciplinary liberal arts education
offering courses in the humanities and social sciences. Together with MAC alumni William Wheeler,David Pearce Penhallow, and William Penn Brooks, Clark put all his effort into the establishment anddevelopment of SAC. One of the major dilemmas of the school arose when Dr. Clark, a devout Christian,made a request to teach students based on his strict Christian beliefs.

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Asia-Pacific Perspectives on Bioethics Education

As a government supported school, it was impossible for Director Kuroda to officially accept his proposal.
However, with the perseverance of Dr. Clark, Director Kuroda decided to unofficially accept instruction
at SAC based on Clark’s Christian beliefs. It is, therefore, not a coincidence that many of the graduatesof SAC, such as Inazo Nitobe, Kanzo Uchimura, Jyo Niijima, etc, served as devout Christians for the restof their lives.
Though Clark’s actual stay at Sapporo was only nine months, he was able to establish the basic systems
required by the new school with the tremendous support of Director Kuroda. Among the early graduatesof the SAC were numerous men who would later influence political, academic, and educational circles
in Japan. In 1907 the college was reorganised again as the College of Agriculture at Tohoku Imperial
University. In 1918 it was once again reorganised, this time as the College of Agriculture at Hokkaido
Imperial University. After reorganisation in 1949, it is presently known as the Department of Agriculture
at Hokkaido University.
Komaba Agricultural School
In 1874, the Noji-shugakujo (Farming Education Institute) employed five instructors from Britain who
lectured on farming, veterinary medicine, and chemistry in English. However, British theory did notmatch with the actual conditions in Japan and graduates were unable to apply their theory into practiceon Japanese farmland. Therefore, German instructors were invited to come to Japan in 1880, when thecontract with the British instructors expired.
As a result, instruction at Komaba Agricultural School quickly converted from the British style to theGerman style. This is partly because academia in Japan began to take a decidedly German slant. German
instructors such as J. L. Yanson (veterinary medicine, arrived 1880), Osker Kellner (horticultural chemistry,
arrived 1881), and M. Fesca (agriculture, arrived 1882) began to lecture on farming practices of theirhome country. Kellner introduced to Japan the Liebig’s research method, which was widely acclaimedin Germany due to its superior results and undertook chemical analysis of farming, particularly to explain
about soil, fertiliser, and plant nutrients.
He was keenly aware of the farming conditions existent in Japan, and focused his attention on paddy
field cultivation. For example, using hydroponics to investigate fertiliser consumption of rice plants, hesought to formulate the most rational standard for fertilisation. In the mornings, he lectured at school
and in the afternoons, he had students experiment with analytical methods. Written records show that
because superior results were being reported to German academia and published in English-language
journals, students zealously pursued their studies. In 1890, Komaba Agricultural School was reorganised
as the College of Agriculture at Tokyo Imperial University, then in 1949 the name was changed to thepresent-day Department of Agriculture of the University of Tokyo. In contrast with Sapporo Agricultural
College, religious influence was limited in Komaba Agricultural College.

Regional Agricultural School
At the beginning of the 1900s, there were strong demands to establish a number of regional advanced
educational institutions in various fields, including agriculture. This resulted in the issuance of theCollege Order in 1903, which helped to establish many agricultural schools. These schools haveplayed a major role in fostering agricultural specialists within Japan. After World War II, many of these
agricultural schools became regular four-year universities.

Second Period (1918-1945)
The second period lasted from 1918 to 1945. The year 1918 saw the proclamation of the University
Order, and all at once many private schools, including Waseda, Keio, Meiji, Hosei, Chuo, Kokugakuin, andDoshisha, were officially sanctioned as universities.

On a discipline-by-discipline basis, the role of humanities and social sciences departments was especially
noteworthy in the nurturing of future salaried workers. Demand for medical practitioners and engineers
also increased. Therefore, universities began to give particular emphasis to professional education. At
the close of World War II, there were 48 universities in Japan with a total of about 100,000 students. This
period can be characterised as “the period of the tremendous expansion of [the] university system”(Nagai, 1965).
Beginning in the early 1900s, the demand to establish many high-level regional technical schools for
instruction in agriculture and other fields increased. This resulted in the promulgation of the College
Order in 1903, under which Sapporo Agricultural College and the Morioka Koto-norin-gakko (Morioka
Higher School of Agriculture and Forestry) were designated as agricultural colleges. By 1914, agricultural
higher schools in Kagoshima (agriculture and forestry), Chiba (horticulture), Ueda (sericulture) andTokyo (agriculture) had also joined the ranks of colleges.
From 1920 to 1924, a new agricultural school was established every year: Tottori and Mie (1921),
Utsunomiya (1922), Gifu (1923), and Miyazaki (1924). Among the distinguishing features during thisperiod were the development and improvement of agricultural education at the secondary level, as
well as the advance of farming instruction for women, and the expansion of facilities for advanced
agricultural training.
In 1914, agriculture alone accounted for 45.4 per cent of the total output of agriculture, fisheries,
mining, and manufacturing, but by 1919, agriculture’s share had fallen to 35.1 per cent, as opposed to
manufacturing’s share of 56.8 per cent. During this period, Japan’s primary production shifted fromfarming to manufacturing.
In 1927, farmers slipped into very hard times and controversy increased over tenant farming (rights,
rents, etc.). During this period, the government was forced to ameliorate this situation in farming
communities.

Third Period (1945-1991)
The third period starts from after World War II, when Japan was governed by General Headquarters(GHQ) under the command of General Douglas MacArthur. As part of the democratisation of Japan, GHQ
made many proposals; central among these was educational reform. To achieve this, the US government
sent an education mission to Japan under the leadership of Dr. George D. Stoddard. A month later, themission submitted its report to General MacArthur on 31st March 1946. The Report of the United States
Education Mission to Japan (1946) highlighted two problems with curriculums at Japanese institutionsof higher education.

Asia-Pacific Perspectives on Bioethics Education

At the same time, a large number of new national universities were being established and the numberof students at institutes of higher education increased 2.5 fold. Underlying this growth was the fact thatfrom 1915 to 1925, Japanese mine and manufacturing production quadrupled, and the demand forcollege-educated salaried workers was steadily increasing.

157

The first was its narrow focus and over emphasis on occupational education due to the early start ofspecialisation, and therefore few opportunities for liberal arts education existed. The second point was
the need to foster more humanistic attitudes to provide a background for freedom of thought and abetter foundation for occupational training.
In addition, the report suggested that “free thinking, adventurous research and action to inspire thepeople” was needed at Japanese universities. Specifically, the report stressed that the most pressing
concerns were the establishment of universities, sexual equality, financial assistance for students, andthe importance of a liberal arts education.

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Asia-Pacific Perspectives on Bioethics Education

In June 1948, the Ministry of Education announced its “Eleven Principles for the Establishment of
National Universities.” The result was that, with the exceptions of Hokkaido, Tokyo, Aichi, Osaka, Kyoto,
and Fukuoka prefectures, all the national post-secondary schools within a prefecture were consolidated
into one university. Following these principles, agricultural schools everywhere became agricultural
departments of new-system universities. As a result, in 1949 there were 24 national universities with 26
departments concerned with agriculture, seven private universities, and eight prefectural universities(six of which were eventually moved to the national system).
In 1956, the Ministry of Education issued its “Standards for the Establishment of Universities” (October
22, Ordinance No.28) and two years later, Nogaku-kankei-gakubu Setchi-kijun-yoko (Standards for the
Establishment of Agriculture-related Departments) with the decision by Daigaku-kijun-toh Kenkyukyogikai (Council on the Standards for the Establishment of Universities) on March 31. These set minimum
standards necessary for the establishment of departments and faculties related to agriculture. Section
One of Article Two of the 1958 “Standards for the Establishment of Agriculture-related Departments”
delineated which primary faculties should be included in any agriculture-related department, whichwere classified according to major discipline. In addition, Article Three stipulated the subjects andcourses which were to be included as special studies in each faculty of these departments. These
ordinances established the framework of agricultural education in Japanese universities and until theStandards for the Establishment of Universities were amended in 1991, the number of universities
increased but their systems remained basically unchanged.

Fourth Period (1991 to 2003)
Japan achieved remarkable economic growth during the 1970s and 1980s. One factor cited as a driving
force behind this growth is the large highly trained workforce that the education system provided.
However, having brought uniformity to education, there have been calls for a “less-pressured education”
and for “education that fosters individuality.” As a result, class hours and curriculums have been reduced
in primary and secondary schools.
In May 1991, the Standards for the Establishment of Universities were amended. Included in thisamendment was a stipulation that “every effort must be made by applicable universities to monitor
and evaluate the current state of their instruction and research activities.” Thus, universities throughout
the country began self-monitoring and self-evaluation programmes of their educational curriculaand research activities. Most universities have reorganised their educational and research system.
Accordingly, the period since 1991 is treated as a fourth period in this report.
The reforms that started in 1991 have taken the form of allocating budgets once the Ministry of
Education has reviewed the proposals submitted by each university. This means that universities, which
had previously been compelled to comply with numerous regulations, now have the freedom to create
their own curriculums. However, it has been suggested that the various revisions have been madebased on the suggestion or comments by Ministry of Education against the proposals submitted by theuniversities. Thus, like previous educational reforms, this reform of the university system was conductedunder the significant influence of the Ministry of Education.
Debate over the reorganisation of agricultural departments, which started in 1991, has considered thefollowing points

1) The decline of the agriculture industry in Japan
During the early 1990s, the cost of food imports decreased due to the rapidly rising exchange rates forthe yen. However, the market price of farm products remained high primarily due to government policy
to maintain domestic agricultural production. This led to criticism from the manufacturing industries
and from people in urban regions casting doubts over the necessity of maintaining the agricultural
sector at the existing scale. These arguments had a strong impact on the reorganisation of agricultural
education programmes at universities.
2) Diversification in career routes for agriculture majors
There has been a diversification in the career routes open to agriculture majors, and it is now not unusual
for the graduates of agricultural majors to find employment in areas unrelated to agriculture. This has
led to discussion on the optimal number of student enrolment in agriculture majors.

As far as we are aware, no lecture course on ethics was offered at an agricultural university in Japan
during Period One through to Period Three. Since the needs of the national goal during this period werefocused on the increase of domestic food production to meet an increasing population, priority was
not given to ethical issues in agricultural programmes. However, ethical issues in agriculture becamea serious matter of concern after Japan experienced rapid economic growth during 1970s and 1980s.
Particularly, after the negative impacts of agricultural chemicals, as pointed out by Rachel Carson in Silent
Spring, first published in 1962. This triggered public concern on the effects of agricultural chemicals on
the human health.

Fifth Period (2004 to present)
It is our current assumption that year 2004 can be considered as the first year of Period Five because of
the fact that “the National University Corporation Law”, a new law governing the national universities,
came into operation. It has long been pointed out that the administration of the national universities
in Japan is under substantial influence of the central government. Under the new law, however, majoremphasis is placed on the autonomy of each national university corporation and the leadership of
the president is highly expected. This has brought fundamental changes in the relationship between
national universities and central government. Another important factor to consider is the rapid decreasein the number of high school graduates due to the sharp decrease of the birth rate.
These two factors have enormous impacts on the overall university education system. Universities inJapan are now required to revise the curriculum in order to attract high school graduates to maintainthe number of enrolment. In this context, it is extremely interesting to look at how each university has
reformed their curriculums and objectives since 1991. However, examining only individual examples, itwill be impossible to gain an overall perspective as the measures taken by the universities have varied
greatly. Thus, an attempt was made to quantitatively analyse the recent changes to the curriculums ofJapanese agricultural universities as a whole.

Current status of bioethics education at agricultural universities in
Japan
To investigate the agricultural education curriculum at universities in Japan, it was first necessary tocreate a database by collecting data about the education curriculums from all universities. Accordingly,
the data on the curriculum of all universities in Japan that had an undergraduate programme in

Asia-Pacific Perspectives on Bioethics Education

Moreover, after a period of steady advancements, the building of an agricultural infrastructure is now
almost complete and improvements in farm productivity have reached their limits. Having achieved
their goals of national agriculture policies, there have even been reductions in production levels, suchas for rice farming. Agriculture’s potential for growth as an industry has lessened, and the numbers of
new agricultural workers has dropped drastically. In school curriculums, agricultural education has lostits clear objective of cultivating self-employed farmers.

159

agriculture from 1983 to the present were collected at the Agricultural and Forestry Research Centre,
University of Tsukuba, and are shown in Figure 1. For reference, the total number of universities and thetotal number of full-time student enrolments in Japan are shown in Figure 2. The number of universities
as well as the total number of fulltime student enrolment has been constantly increasing since 1949.
， Hokkaido Univ.
， Rakuno Gakuen Univ.

， National Universities， Prefectural Universities， Private Universities， Hirosaki Univ
， Kitasato Univ.

， Fukui Prefectural Univ.

， Akita Prefectural Univ.

， The Univ. of Shiga Prefecture， Yamagata Univ.

， Kyoto Univ.
， Kyoto Prefectural Univ.

， Niigata Univ.

， Kobe Univ.

， Shinsyu Univ.

， Tottori Univ.

， Gifu Univ.

， Obihiro Univ. of Agriculture
and Veterinary Medicine， Iwate Univ.

， Okayama Univ.

， Tohoku Univ.

， Shimane Univ.

， Utsunomiya Univ.

， Hiroshima Univ.
， Hiroshima Prefctural Univ.

， Ibaraki Univ.
， Univ.of Tsukuba， Chiba Univ.

， Yamaguchi Univ.

， The Univ. of Tokyo， Tokyo Univ. of Agriculture and Technology， Tamagawa Univ.
， Tokyo Univ. of Agriculture (Fac. of Agriculture)， Nippon Veterinary and Animal Science Univ.

， Kyusyu Univ.
， Saga Univ.
， Kyusyu Tokai Univ.

Asia-Pacific Perspectives on Bioethics Education， Kagoshima Univ.

160， Tokyo Univ.of Agriculture(Faculty of Bioindustry)， Univ. of the Ryukyus， Kagawa Univ.
， Kochi Univ.
， Ehime Univ.
， Miyazaki Univ.
， Minami Kyusyu Univ.

， Mie Univ.
， Kinki Univ.

， Nagoya Univ.
， Meijo Univ.

， Osaka Prefecture Univ.

， Nihon Univ.
， Meiji Univ.
， Azabu Univ.
， Shizuoka Univ.

Fig. 1 Location of the University that has
College of Agriculture in Japan(as of 2006)

Fig. 2The number of universities that have undergraduate agricultural programmes (Agricultural major) andthe number of departments (educational unit) in agricultural areas are shown in Figure 3. The number ofuniversities that have agricultural departments (typically called Noh-Gakubu in Japanese) has increased
from 47 in 1983 to 51 in 2003. Recent increases in the numbers of agricultural departments can be
explained by the conversion of regional junior colleges (two year programmes) into four year regular
universities. The same kind of conversion from junior college to university can be observed in many
academic areas including humanity sciences, social sciences and natural sciences. The major driving
force to convert junior colleges into universities is to facilitate the recruitment of newly graduated highschool students. The student recruitment is very important for school management, since the number

of high school graduates is expected to decrease due to the reduction of the birth rate.

Number of Universities and Faculties

70
Number of Departments

65

55
50
45
40

61

Number of Universities
with Ag Majors

60
48

51
47

35
30
85

87

89

91

93

95

97

99

01

Figure 3. Number of Agricultural Universities in Japan

03
Year

In order to analyse the educational programme at agricultural universities in Japan, the data wascollected and compiled into the “Database of Agricultural Education Curriculums at Universities inJapan (“AgBase”). The survey covers all agricultural fields apart from those related to fisheries. To
date, 519,244 records have been registered into the database covering data from 1983 to 2005, andover 20,0000 records are being added each year. The data covers the following nine items: 1. Year, 2.
University name, 3. Department name, 4. Majors, 5. Course title, 6. Class attributes, 7. Standard year of
study, 8. Number of credits, 9. Whether compulsory or elective.
Figure 4: Numbers of majors and proportion of the compulsary courses at agricultural universities
in Japan

60

320
300

50

281

40

280
260

30

33.4

Number of Majors

240

23.7

Number of Majors
Compulsory Courses (%)

220

20
10

Compulsory Courses (%)

300

0

200
83

85

87

89

91

93

95

97

99

01

03

Year

Microsoft Access was used for the creation and management of the database, using Visual Basic to analyse
the data. The results of the analysis of “AgBase” showed that Department of Agricultural Economics of
Hokkaido University was the only university that offered an ethics course at the undergraduate levelfrom 1983 to 1992. It was called an “Introduction to the ethics”. In 1993, 11 universities started to offer
ethics courses and the number increased to 31 universities in 2005. Among these 31 universities, 19
universities offered a single course, nine universities offered two courses, two universities offered three

Asia-Pacific Perspectives on Bioethics Education

83

161

162

Asia-Pacific Perspectives on Bioethics Education

courses, and one university offered four different ethics courses.

As shown in Table One, the most popular course title on ethics was “Ethics for Engineers” in 2005. Most
likely, this course was offered within the agricultural engineering department, where credit on ethics isrequired to acquire certification for professional engineers (PE). “Bioethics” was the second most popular
course title (nine Universities) followed by “Environmental Ethics” (eight universities).
Table 1: List of courses on Ethics offered at Agricultural Universities in Japan (2005)

Course title#
Universities#
Universities

Course title

Ethics for Engineers

15

Veterinary Ethics

5

Bioethics

9

Ethicsinenterprises

Environmental Ethics

8

Ethics in Agriculture2

Ethics in Science andTechnology

5

Ethics

2

Total

48

private

2

These tendencies are fairly understandable due to the importance of nurturing an ethical way of thinking
in the area of agriculture. Unexpectedly, only five out of 16 veterinary programmes offered a course on
ethics as of 2005. The clinical veterinarians play a central role in health and hygiene management ofcommodity animals, companion animals and wild animals. Ethical issues related to animal welfare andmanagement should be taught in all of the veterinary programmes.
The agricultural universities in Japan are currently under major reformation to cope with the rapidlychanging social, environmental and technological circumstances. Among the many agendas to reform,
education on ethics is undoubtedly becoming one of the key issues for the agricultural programmes.
This is because food produced by the unethical use of agricultural technologies to modify the phenotype
of commodity animals and plants, is not accepted by the consumers.

Furthermore, many of the technologies to control human reproduction, such as cryopreservation of
sperm and egg, in vitro fertilization, embryo transfer, etc, were originally developed by researchersof agriculture sciences. The hot discussion on the production of cloned human embryos was started
immediately after the birth of “Dolly the sheep”, the first somatic cloned mammal was produced at the
Roslin Institute, a research institute on animal agriculture in England (Wilmut et al. 1997).
It is therefore essential for the agricultural university to provide systematic curricula on bioethics toeducate future agricultural researchers. In fact, one of the major scientific journals in the area of animal
science called Livestock Science published by Elsevier, devoted an entire issue on “Ethics in Animal
Agriculture” in September 2006 (Livestock Science, 2006). Furthermore, Chrispeels and Mandoli (2003)
published a paper entitled “Agricultural Ethics” in Plant Physiology, a scientific journal on plant science.

In conclusion, the importance of the ethical issues in agriculture is becoming recognised among
agricultural universities but the percentage of universities that actually offer the lecture course on ethics
is still limited to 61 per cent of the 51 universities that have undergraduate agricultural programmes.
Continuing quantitative expansion and qualitative enrichment of the subjects on ethics are apparently
necessary in agricultural programmes at universities in Japan. One hundred years has passed since theword “ethics” was translated into Japanese as Rinri by Tesujiro Inoue (1855-1944), a philosopher teachingat the University of Tokyo. Ethical issues inevitably have become one of the key educational componentsof agricultural programmes at universities in Japan.

References
Chrispeels MJ, Dina F. and Mandoli DF (2003) Agricultural Ethics. Plant Physiology Vol. 132, pp. 4–9.
FAO (2001a) Report of the Panel of Eminent Experts on Ethics in Food and Agriculture, First session. ftp://ftp.
fao.org/docrep/fao/003/x9600e/x9600e00.pdf Rome: Food and Agricultural Organization.
FAO (2001b) FAO Ethics Series 1: Ethical issues in food and agriculture. Rome: Food and Agricultural
Organization. ISBN 92-5-104559-3
FAO (2001c) Ethics Series-2 Genetically modified organisms, consumers, food safety and the environment.
Rome: Food and Agricultural Organization. ISBN 92-5-104560-7
FAO (2004) Ethics Series-3 The ethics of sustainable agricultural intensification. Rome: Food and Agricultural
Organization. ISBN 92-5-105067-8
FAO (2005) Ethics Series-4 Ethical Issues in Fisheries. Rome: Food and Agricultural Organization. ISBN
92-5-105322-7
Livestock Science (2006). Special issue: Ethics in Animal Agriculture. Livestock Science Vol. 103, No. 3,
pp.203-307.
Macer, DRJ., Bhardwaj, M., Maekawa, F., and Niimura, Y. (2003) Ethical Opportunities in Global Agriculture,
Fisheries and Forestry: The role for FAO. Journal of Agricultural and Environmental Ethics, Vol. 16, pp.479504.
Nagai M. (1965), University in Japan. Chuo-Koron Shinnsho Vol. 61.
The Report of the United States Education Mission to Japan (1946) Submitted to the Supreme
Commander for the Allied Powers.
Wilmut, I., Schnieke, A.E., J. Mcwhir, J. Kind A.J. and Campbell K.H.S. (1997) Viable offspring derived from
foetal and adult mammalian cells. Nature, Vol. 385, pp.810-813.

Asia-Pacific Perspectives on Bioethics Education

Conclusion

163

Appendix A:
Structure of the current formal education system in Japan is as follows (Information provided by Ministryof Education, science, culture and sports. The original information can be accessed at http://www.mext.
go.jp/english/org/f_formal_22.htm)
Compulsory education
Elementary school aims to provide children aged between six and 12 with six years of general elementary
education suited to the relevant stage of their physical and mental development. Lower secondary
school aims to provide children between 12 and 15 with three years of general secondary education
suited to the relevant stage of their physical and mental development, based on the education they
have received in elementary school.

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Asia-Pacific Perspectives on Bioethics Education

Upper secondary education
Upper secondary school provides children who have completed compulsory education with bothgeneral and specialised upper secondary education. Upper secondary school subjects include general
educational courses (ordinary courses) and specialised subject courses (specialised courses) such as
agriculture, industry, business, fisheries, home economics, nursing, information, welfare, science,
mathematics and English language. However, as a part of the reforms made in upper secondary
education, in April 1994, a newly established integrated course programme went into effect, which
provides general and specialised education on an elective basis to students. In addition, some upper
secondary schools offer part-time and correspondence courses to working young people.
Outline of higher education
The institutions for higher education in Japan consist of universities, junior colleges, colleges oftechnology and specialised training colleges (specialised schools) which offer specialised courses. Since
the end of World War, the scale of higher education in Japan has expanded remarkably, particularlyin the number of private institutions. Today the scale of higher education in Japan ranks among thehighest in the world.
(1) Universities and graduate schools: The purpose of universities, as the centres of advanced learning,
is to provide students with wide-ranging knowledge and to conduct in-depth teaching and research in
specialised academic disciplines. The term of study is four years (six years for medicine, dentistry andveterinary medicine). Graduates are awarded a bachelor’s degree.
A university may also establish a graduate school offering master courses (two-year standard term ofstudy) and doctoral courses (five-year standard term of study: four years for medicine, dentistry andveterinarian medicine) or professional degree courses (two-year standard term of study; however,depending on the field in some cases it can take between one and two years or more than three
years). Those who have completed the graduate course are awarded either a masters, a doctorate or aprofessional degree.
(2) Junior colleges: The purpose of junior colleges is to conduct in-depth learning and research in
specialised disciplines and to develop abilities necessary for employment and daily life. The term ofstudy is two or three years and the graduates are awarded the title of associate.
(3) Colleges of technology: The purpose of colleges of technology is to conduct in-depth learningin specialised disciplines and to develop students’ abilities necessary for employment. Colleges oftechnology, unlike universities or junior colleges, admit graduates of lower secondary schools. The termof study is five years (five and a half years for mercantile marine studies) and graduates are awarded thetitle of associate.

*

Paper first presented at the joint UNESCO:UNU-IAS Roundtable on Japanese Perspectives on Bioethics Education
held in Yokohama, Japan in February, 2007

Bioethics as a challenge*
Tomoaki Tsuchida, Ph.D.,
Waseda University,
Japan

Introduction

This is mainly because of incessant developments in medicine as science and technology which force
us to think afresh of a better way of coping ethically with what we can do technologically. It is also
because of the expansion or deepening of our horizons as to how we view our own immediate life in
its interrelatedness with the lives of other people in the world and in the future. We are more and more
realising the fact that our life is linked to not only other lives in other parts of the world but also to lives
in the future.
Bioethics is not merely a concern about a patient’s rights or patient-centred medicine, or the patientphysician relationship. It was at its outset, as we know from the spirit of Nuremberg code and theHelsinki Declaration and others, sometimes regarded as a set of principles and guidelines safeguarding
the human rights of patients or research subjects. But as procreational tourism or the organ-transplanttrade become rampant and enhancement medicine became a huge industry in developed countries,
whereas in developing countries there is not enough food and clean water supply, let alone primary
medical care, bioethics cannot remain concerned about patients’ rights alone.
When neuroscience and genetics are becoming more able to investigate and invade into what and howeach one of us thinks and behaves, bioethics has to re-examine its raison d’être.
Yet, this means that the basic spirit of bioethics remains and is ever more important, namely; its concern
about human dignity and respect for the person, even though the content of these notions are notimmediately given clearly and simply.
Bioethics mirrors problematic situations concerning our life and society and the world and asks us tothink afresh about this life of yours and mine, life on the planet, more and more humanely. Bioethics
remains a process of mutual education, not merely a set of principles and/or codes and guidelines, nor abusiness of a bunch of academics or their discipline in academia. It has to go beyond the institutionalised
subject of academic courses taught by bioethicists, and it also has to help change our view of school
education which is part of the institutional devices of the modern age.

Education in Japan
Now let us turn to the state of education in Japan and we notice that it is in a critical situation, if not
in a shambles. In the midst of affluent society where one can pursue one’s desire freely around theclock, young people are not interested anymore in education, that is, drawing on the possibility ofdeveloping what one as a whole human person can become through encounters with other persons
and the world.
It has been pointed out over these two or three decades that students are interested only in the

Asia-Pacific Perspectives on Bioethics Education

Teaching courses in bioethics for years and occasionally presenting my views in academic societies,
I think bioethics is not only an academic discipline, rigorously surveying and analysing the ethicalimplications of biomedicine and health care, but it is also a movement concerning the state of humanlife and health involving not only academics, but also common citizens. It is always raising questions
and asking us to probe our way together in search of a better view of health, and better agreements on
health practices, policies, etc.

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instruction which they deem amusing, easy and useful to them. In other words, they satisfy themselveswith whatever comes their way conveniently, virtually or materially, and are becoming more envelopedin themselves. Narcissistic as they are, they avoid confronting or encountering other individuals andsituations different from what they regard as relevant to their interests. Japanese children as well as
those in other East Asian countries, tend to score well in school subjects but they are neither enthusiastic
nor truly interested in learning, for instance, from natural science or about other people in the world(as every educational indicator comparatively studying school children’s attitudes and academic
achievements shows).

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Asia-Pacific Perspectives on Bioethics Education

Quite a few students are interested only in scoring good grades so that they may succeed in schools, go
on to colleges and universities, and gain advantages in a harshly competitive society. As knowledge inour days accelerates in its quantity and in its abstractness and sophistication, it is increasingly difficult
to live up to the current level of specialty and expertise and come up to the point from which to have agood perspective of how we are and how humanity is, how the universe is, etc.
We are tempted to get ensconced in an ever smaller speciality or private pursuit of whatever happens tocome our way. People enjoy more uniform amenities, commodities and what the mass media offers, andyet they tend to live in a more withdrawn lifestyle meticulously and nervously guarding their privacy.
Naïve interest in being in the world with other beings and cooperating with other people is getting
weaker. If young people tend to be content with what is convenient to them and are not interested
in encountering what is different from their individual temperament and divertissement, education in
its original sense and ideals is bound to wither. Hundreds of thousands of young people in Japan arewithdrawing from society, confining themselves in their room at home or doing no work or schooling(so-called NEETs). We are in dire crisis as a society, for what we witness is not just a crisis of education
but it is a crisis for being a human being in the world.
Telling young people to study hard so that they may become successful in society, so that they may
contribute to the competitive nation-building has its significance. It is high time, however, to realise thatbeing a good person concerned about other living beings is as important or more so. Here, bioethics
comes in as a basic humane subject for all students, common concern for students in different majors,whether one is interested in social science or natural science or humanities. That requires, as I see it, achange or broadening of scope of bioethics education.

E-School
Let me described in the remainder of the paper what I have been doing at Waseda University. At our
School of Human Sciences. Waseda University, we have started a so-called e-School or on-demand
method correspondence school where students are in various stages of life, some young, some old, andin all walks of life, workers, homemakers, retirees. Among students I have in my bioethics course at thee-school, there are nurses, pharmacists, nutritionists care-providers, and so forth. While they attend mycourse on the Internet, students write in their views and comments and share them among themselves
and with their educational coaches. This discussion on the web goes on as the course progresses
with different issues each time, giving a forum to participating students. I too benefit from what theyexchange among themselves. This form of education is one way of opening the vista of bioethics as not
merely a course but as a practice of ethics concerning the state of human life and health.

Bioethics and other practical ethics
The modern world is run by sophisticated and complex civilizational systems, with people in manydifferent roles and capacities, with each of their professional specialties collaborating together.
Sometimes the degree of specialisation is such that if people are in different occupations or professions,they do not understand each other’s specialty at all. The traditional community and religion/ideology are
falling apart; we are divided among ourselves, not sharing much in common except mass consumerism
propelled by mass production and mass media. In these circumstances it is ethical concern as fellow
humans that bonds us together and keeps us humane. In keeping with diversified professions andvarious roles which constitute the society, ethics in our days, too, is envisioned and practiced as practicaland professional ethics, such as research ethics and engineering ethics, media ethics, business ethics,
and so on.
At the core of all practical and professional ethics are bioethics and environmental ethics. Respect foreach person and human dignity are cardinal to all people in the world. I have been involved in research
ethics committees and teaching research ethics and I think it necessary to have the liaison with otherpractical ethics and cultivate students interest in them too so that ethical sense, ethical imagination,
ethical concern may be considered essential in our world to have unity as humans responsible not only
for ourselves, but also for posterity and for the environment. At the core, to repeat, is a bioethical concern
because it concerns the life and health of everyone, even if they do not engage in a profession.

A comparative eye

Yet if we look at human predicaments of suffering from illness, ageing and death, which are common
to all of us humans, and which make us reflect on being human and humans and think together as towhat is good as humans as part of living beings on the planet, we could be united in ethical concern
for each other. For one thing, instead of segregating the sick, the elderly or the dying in institutions, weneed to be communicating with people in suffering. For another, by teaching about the reality of organtransplant tourism, the curiously high suicide rate among Japanese, or the German sensitivity about ES
cell research, we will come to see our situation of life better and consider what health is, and so forth.
We need to develop comparative eyes in bioethics teaching.
In this sense, bioethics is an ever new challenge soliciting us to radically re-examine our way of thinking
and doing concerning life and health. It is a challenge for Japanese teachers and students, enablingthem to look at themselves as part of the human family, sharing human suffering and concern for eachother. Concern and learning about human suffering, not only of my own and of my loved ones, but alsoof other people in other parts of the world will be educational and will help people to be more humane.
We need to accept the challenges bioethics harbours in itself and develop bioethics better through thissort of international exchange of views through UNESCO and the United Nations University.

Asia-Pacific Perspectives on Bioethics Education

We know we need to develop the awareness that the world is one, sharing one and only planet, andthat we are humans in so far as we share the concern for each other and for the environment has cometo us men and women after many thousands of years of conflicts and exploitations and blindness to thechain of beings. Now at last we are keenly aware of this ecological oneness and the common human
responsibility to it at the time when we are threatened by the global crisis of environment which is, inturn, closely linked to a crisis of humanity in the aftermath of the loss of great traditions.

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L’enseignement De L’ethique De La Science Et De La
Technologie Dans Les Universites Africaines*
Christophe Kwami Dikenou.
Université de Lomé, Togo

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Asia-Pacific Perspectives on Bioethics Education

L’enseignement de l’éthique de la science et de la technologie couvrant des domaines de l’éthiqueappliquée comme la bioéthique, l’éthique de l’environnement, l’éthique des sciences dans les universités
africaines est de plus en plus reconnu comme une nécessité. L’évaluation des méfaits et bienfaits desavancées et applications de la technoscience n’est plus l’apanage de certaines personnes ou de certaines
universités des pays développés depuis la Conférence mondiale sur la science organisée par l’UNESCO
et le CIUS à Budapest (Hongrie) en 1999. En effet, la Déclaration sur la science et l’utilisation du savoir
scientifique adoptée à cette Conférence stipule en son article 41 que«Tous les scientifiques devraient s’engager à respecter des normes éthiques rigoureuses et il
faudrait établir, sur la base des normes pertinentes énoncées dans les instruments internationaux
relatifs aux droits de l’homme, un code de déontologie à l’usage des professions scientifiques.
(…) Les programmes d’enseignement des sciences devraient inclure l’éthique scientifique, ainsi
qu’une formation concernant l’histoire, la philosophie et l’impact culturel de la science.»
Il s’agit des scientifiques du monde entier. Aussi actuellement sur le continent africain met-on en route
plusieurs initiatives tendant à favoriser particulièrement l’enseignement de la bioéthique et la formationde réseaux ouverts aux chercheurs et enseignants de bioéthique. On peut, à ce propos, citer les exemples
de PABIN (Pan African Bioethics Initiative) des Premières journées de bioéthique pour l’Afrique de l’Ouest
et du Centre. Des centres de formations en bioéthique sont fonctionnels sur le continent dont la South
African Research Ethics Training Initiative (SARETI), Health Research Ethics Training Initiative in Egypt(HRETIE), West African Bioethics Training Programm.
Des initiatives de cours se prennent dans différentes universités par des philosophes, juristes etmédecins.
Notre objectif, dans cet exposé, n’est pas tant de faire le bilan de l’enseignement de l’éthique de lascience et de la technologie qui n’est qu’à ses débuts, mais plutôt de faire un plaidoyer argumenté pourplus de solidarité et de coopération multilatérale et bilatérale en vue du renforcement des capacités desuniversités africaines pour cet enseignement.

Pourquoi renforcer l’enseignement de l’éthique dans les universités
africaines?
En Afrique, quelques universitaires qu’il s’agisse de philosophes ou autres redécouvrent laquestion éthique fondamentale kantienne du « que faire » pour bien faire face à la mondialisationde la technoscience « omniprésente » dans quelques principaux domaines comme la santé, lescommunications, l’environnement, l’alimentation et l’énergie.
La santé : Dans le domaine de la santé, s’accentue le souci de la responsabilité de la communauté humained’employer la technoscience à promouvoir la santé publique et un égal accès aux médicaments et aux
soins de santé d’une part et de l’autre le souci des bonnes pratiques en matière d’expérimentation
sur des sujets humains, et embryons humains, ou encore en matière de procréatique, de fin de vie,de transplantation d’organes et de tissus, et de manipulation génétique. Les Africains s’intéressent
entre autres, à se doter de réglementations éthique et juridique afin de réduire l’exploitation de leur*Paper first presented at the First UNESCO Bangkok Bioethics Roundtable, September, 2005

contient comme « paradis » de recherches biomédicales et biopharmaceutiques et d’essais cliniques. Ils
se préoccupent également de l’accès équitable des populations vulnérables aux soins de santé et aux
produits pharmaceutiques.
Les communications : La société actuelle se caractérise par l’avènement d’une société de l’information
qui se réalise grâce à l’apport de la science et de la technologie à l’information. Elle n’est pas sans susciterdes questions éthiques liées à la production et à la consommation de l’information, au souci du choix
des techniques d’information à développer. Dans ce domaine, les Africains s’intéressent, entre autres,
plus à un accès équitable aux Nouvelles Technologies de l’Information et au respect et à la sauvegardede leurs identités culturelles face aux communications transnationales.
L’environnement
L’augmentation de la détérioration de l’environnement due aux activités humaines a amené à larecherche de normes éthiques devant guider l’agir humain vis-à-vis de l’environnement.
L’Afrique possède d’abondantes ressources naturelles. Paradoxalement l’exploration et l’exploitation deces ressources demeurent un facteur de dégradation de l’environnement et d’exploitation inéquitable.
L’application des sciences et des technologies, dans ce domaine, si elle est fondée sur des valeurséthiques peut contribuer à la préservation des ressources et à la croissance économique nationale.

La manipulation génétique dans le domaine de l’agriculture et de l’élevage qui s’accélèrent depuis lesannées 60 suscite des questions éthiques liées au souci de trouver et de garantir le respect de normessûres tant pour la production que pour la consommation d’organismes génétiquement modifiés, demême que pour permettre à tous les pays particulièrement africains un accès équitable à la technologie
et aux bienfaits qui en découlent.
L’énergie
Le recours aux progrès de la technoscience pour résoudre les problèmes de pénuries énergétiquess’accélère depuis quelques années, mais il n’est pas sans susciter des controverses sur la façon éthiqued’agir.
Tels sont certains des principaux domaines où la technoscience est «omniprésente» et suscite desmutations sociales qui obligent à formuler ou à reformuler nombre de questions et de réponses éthiques
qui constituent de véritables défis pour la communauté internationale y compris l’Afrique. Ces défisinterpellent les établissements d’éducation sur le type de citoyen qu’ils veulent contribuer à former.
Dès lors, pour participer efficacement à ce débat collectif, comme nous le disions plus haut, desinitiatives se prennent particulièrement par des universitaires africains afin de contribuer à développer
les compétences éthiques des étudiants, futurs responsables.

Comment aller de l’avant?
Les initiatives de cours et de centres de formation en bioéthique qui voient le jour sur le continent
ont besoin d’être connectées en réseaux et renforcées comme le recommande la Déclaration de Dakar
de juillet 2005. Dans cet ordre d’idée, il serait salutaire que les pays africains, dans les années à venir,collaborent davantage avec le Programme de l’UNESCO sur l’Ethique des sciences et de la technologie
et que la COMEST mette à la disposition d’un grand nombre d’universités africaines le rapport
intitulé : L’enseignement de l’éthique qu’elle a adopté en 2003 à Rio de Janeiro, Brésil, afin que cellesci se l’approprient en l’adaptant aux réalités nationales. Cet enseignement doit avoir une base légale
nationale.
L’enseignement de l’éthique de la science et de la technologie sur le continent africain est indispensable.
S’il est vrai que l’Afrique traditionnelle attachait une grande importance à l’éducation morale commeAsia-Pacific Perspectives on Bioethics Education

L’alimentation

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170

Asia-Pacific Perspectives on Bioethics Educationbase de l’éducation particulièrement dans la famille et les camps d’initiation, malheureusement on
assiste actuellement à un affaiblissement des remparts des valeurs morales que constituaient la famille,
les communautés initiatiques voire religieuses. Ces institutions éducatrices à la morale ont de moins en
moins d’influence sur une société plurielle. Par ailleurs, elles s’avouent incompétentes à donner des avis
normatifs sur les problèmes éthiques que suscite la technoscience contemporaine. D’où la nécessité desrecherches approfondies sur les traditions africaines ; recherches qui impérativement devront demeurer
très attentives aux conclusions et théories des sciences contemporaines.
Par ailleurs, il faut reconnaître que l’enseignement de l’éthique fondamentale et de l’éthique appliquée
est difficile, car il est une vocation et une technique pédagogique qui contribuent à développer le bien età lutter contre le mal chez l’apprenant. Malgré cela, il constitue la seule activité qui permet à l’apprenantde développer l’aptitude à identifier et à analyser les problèmes éthiques de façon à prendre de manière
autonome ses décisions éthiques. Il équipe l’apprenant en science à ne pas s’isoler des sciences sociales
et humaines, tout comme l’apprenant en sciences sociales et humaines à s’intéresser aux informations
scientifiques. Bref, l’enseignement de l’éthique de la science et de la technologie permet de combler le« fossé » entre les sciences et les valeurs humanistes dont parlait le fondateur de la bioéthique Van R.
POTTER. Par conséquent on ne s’improvise pas enseignant-chercheur en éthique ; il faut une formation
initiale et continue. Dans cet ordre d’idée les plus gros obstacles auxquels l’enseignement de l’éthiquede la science et de la technologie fait face dans les universités africaines sont le manque de ressources
humaines hautement qualifiées en éthique appliquée et le manque de documents récents et appropriés.
Si ces obstacles majeurs sont levés grâce à la coopération internationale et interuniversitaire, l’ensembledes établissements universitaires peut développer la compétence des étudiants et étudiantes dansla plupart des disciplines enseignées et dans des cours spécifiques d’éthique, et par des activités
parauniversitaires tels des services à la collectivité.
A ce propos, les cours spécifiques d’éthique dispensés dans les départements de philosophie
constituent des cadres privilégiés pour développer des enseignements menant au doctorat en éthiqueet approfondir la réflexion en lien avec les problèmes éthiques actuels consécutifs aux avancées etapplications de la technoscience
Au premier et second cycle, l’ensemble des disciplines scientifiques peut contribuer à développer lacompétence éthique aujourd’hui plus nécessaire aux scientifiques qu’au temps où François Rebelais
disait que « science sans conscience n’est que ruine de l’âme ». La pratique des sciences de la nature est
indissociable d’une éthique de la science, de la recherche scientifique, et du souci de l’environnement.
La pratique de la médecine est indissociable d’une éthique médicale, de la recherche biomédicale del’expérimentation sur les êtres humains et autres. La pratique des sciences sociales et humaines est liée
à l’éthique de la citoyenneté démocratique indissociable d’une compréhension suffisante de la sécurité
environnementale, et des questions scientifiques.
En conclusion, l’Afrique n’est pas épargnée par les sérieux défis et dilemmes éthiques qu’entraînent
les avancées et applications de la technoscience. Le renforcement des capacités en Afrique en vue dedévelopper la compétence éthique des futurs scientifiques et technologues tout comme des futurs
spécialistes des sciences sociales et humaines interpelle la solidarité et la coopération internationales.

Joint plan of action for regional networking inbioethics education towards better bioethics
education*
We are participants at the UNESCO Asia-Pacific Conference on Bioethics Education, held 26-28 July
2006 in Seoul, Republic of Korea. Together with other members of the UNESCO Asia-Pacific School of
Ethics we adopt the following joint plan of action:

1. Rationale for bioethics education (Reason for actions)
Given the rapid development of science and technology, for example, genetic engineering, neuronengineering, and nanotechnology, and the implications these raise for individuals and society, people
need to have the opportunity to shape the direction, purposes and goals of science and technology.

Bioethics includes ethical issues related to (all branches of knowledge, including) the environment, life
sciences, and medicine and associated technologies, and the participants at this conference accepted
the broadest possible understanding of bioethics. They also recognise that many of the same points
can be said for development of education to address the ethical issues associated with science andtechnology in general.
To ensure public participation and making wise decisions about their and their children’s future,providing bioethics education at all levels is necessary.
As individuals from some of the member states who have agreed to Declarations on Bioethics, werecognise that working together as a regional network will be an effective means of achieving the goals
below. Taken together, there is a need for people to be able to express/discuss their values throughbioethics education for all groups of human society.

2. The societal mandate for bioethics education
We remind governments and all persons involved in bioethics education of the commitments made in
the Declarations adopted by all member states of UNESCO relating to bioethics education, specifically
including:
Universal Declaration on the Human Genome and Human Rights (adopted by the UNESCO
General Conference 1997 and endorsed by the UN General Assembly 1998)“20 States should take appropriate measures to promote the principles set out in the Declaration,
through education and relevant means, inter alia through the conduct of research and training ininterdisciplinary fields and through the promotion of education in bioethics, at all levels, in particular
for those responsible for science policies.”
Universal Declaration on Bioethics and Human Rights (adopted by the UNESCO General
Conference 2005)“23. (i) In order to promote the principles set out in this Declaration and to achieve a better
understanding of the ethical implications of scientific and technological developments, in particularin young people, States should endeavour to foster bioethics education and training at all levels as wellas to encourage information and knowledge dissemination programmes about bioethics. (ii) Statesshould encourage the participation of international and regional intergovernmental organisations*

Statement adopted and revised by participants of the International Bioethics Education Network and members of
the UNESCO Asia-Pacific School of Ethics at the UNESCO Asia-Pacific Conference on Bioethics Education, held 26-28
July 2006 in Seoul, Republic of Korea.

Asia-Pacific Perspectives on Bioethics Education

Societies and communities will progress in a more just, equitable and sustainable direction if thecultural, ethical, and spiritual values of those societies are central determinants in shaping technology
and science.

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and international, regional and national non-governmental organisations in this endeavour.”

3. GoalsResearch has shown that there are a number of goals of bioethics education including:a) Knowledge• Development of trans-disciplinary content knowledge;• Understanding the advanced biological concepts;• Being able to integrate the use of scientific knowledge, facts and ethical principles and argumentation in
discussing cases involving moral dilemmas;• Understanding the breadth of questions that are posed by advanced science and technology;• Knowledge of cultural values.

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Asia-Pacific Perspectives on Bioethics Educationb) Skills (capacity building in skill acquiring should be multi faceted or many sided, and the goals
include):• Balancing benefits and risks of Science and Technology;• Being able to undertake a risk/benefit analysis;• Develop critical thinking and decision making skills and reflective processes• Develop creative thinking skills;• Develop foresight ability to evade possible risks of science and technology;• Skills for developing “informed choice”;• The required skills to detect bias in scientific method, interpretation and presentation of research results.
c) Personal moral development:• Understanding better the diversity of views of different persons;• Increasing respect for all forms of life;• Elicit a sense of moral obligation and values including honesty and responsibility;• Being able to take different viewpoints to issues including both bio-centric and eco-centric worldviews
rather than only anthropocentric perspectives;• Increasing respect for different people and culture, and their values;• Developing scientific attitudes, reflective processes, and an ability for holistic appraisal, while notignoring the value for reductionist analysis;• Knowledge about bias in the interpretation and presentation of research results, benefits and risks oftechnology and bioethical issues, and how to detect bias;• Exploration of morals/values (values clarification);• Values analysis and value based utilization of our scarce natural resources;
We note that many of these goals apply to ethics education and (education) development of criticalthinking in general.

4. Implementation challenges
We applaud the efforts made by those involved in bioethics education to date, and UNESCO for
convening this conference, as well as other meetings with the goal of building capacity in the region forteaching bioethics.
We call for increased support for implementation of all methods for bioethics education at all levels in
culturally appropriate ways. Sound discussion of the underlying values and cultural factors in setting

these targets is important.

• using objectiveness in evaluation;• training more professionals (teachers, medical experts, philosophers, industrialists, engineers, managers,etc.);• developing a wider range of appropriate support materials for different contexts/situations;• increasing the time allocated to the teaching of bioethics;• increasing the value or credit given to bioethics components of courses or bioethics courses;• developing teaching and learning methods that encourage motivation to learn about bioethics;• encouraging scientists to engage with bioethics;• integrating all forms of ethics education into the core curriculum (main-streaming);• extending ethics consultation systems;• in all these aspects to conduct research that can find the best method to develop concrete
mainstreaming of ethics into subunits and blocks into the curriculum;• Fostering team spirit and healthy inter-personal relationship among team members and networking
personals;• Establishment of teaching resource and research centres open to all.

5. Targets
There are a variety of targets of bioethics education. We identified specific target groups for bioethics
education, and conducted workshops on some of these. There were many overlapping needs, includinggroups such as:• The General Public (and cooperation with the public media). Influencing the government to develop
better policy in science and research, and update this to address social needs;• Educational institutions including: Primary schools, High School, and Universities;• Scientists and Graduate School;• Students in Health Sciences and Technology Professions, Basic Sciences, Social Sciences, Engineering,
Economics, Management and other non-science majors;• Government officials and Ministers;• Media and journalists;• Legal profession, Economists and administrators.

6. Curriculum development
Some general features need to be considered, although every culture needs to develop their own
curriculum appropriate to their values and culture. Participants are ready to assist in the delivery ofthese goals.
Dedicated time for a bioethics curriculum needs to be integrated and administered.
Curriculum development workshops for in service and pre-service teachers, and for all levels of
education, primary secondary and tertiary, need to be organised, in the context of values education.
Development of integrated curricula across all levels of education that develop critical thinking skills
and critical analysis.
Cross curriculum cooperation between different academic disciplines, and development of atransdisciplinary curriculum.
Ongoing assessment of curriculum and continuing modification thereof.

Asia-Pacific Perspectives on Bioethics Education

We will work to overcome obstacles for implementing bioethics education by all available methods
including:173

7. Teaching materials
We call for all teaching materials to be made openly available for free download on the Internet.
Production and sharing of free on-line teaching materials for bioethics education in different languages
with a variety of cases from different cultures. Collection of multiple materials in multiple languages.
Sharing of materials requires adequate dissemination plans.
Researchers and educators to work together across cultures to compile and produce materials which
can be used at a variety of levels, including both school and college classes to teach about bioethics.
We call for an extension to existing compilations of materials, such as Macer, D.R.J., ed., A Cross-Cultural
Introduction to Bioethics (2006).
Development and improvement of the teaching resources, such as Videos and DVDs. A repository ofcase reports by countries/regions needs to be established.
Introducing different cultural and religious practices in response to bioethical dilemmas.
Establishment of Bioethics Teaching and Learning Resource Centres.

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Asia-Pacific Perspectives on Bioethics Education

8. Teaching methods
Providing different types of teaching methods and models for different target groups such as lectures,
seminars, workshops, drama, narrative, role plays, case presentations and analysis, essay composition,
small group discussion, on-line discussion forums, newsletters, public discussions, media commentaryand critiques, all have important roles in accomplishing the above goals.
Generating sustainable ethics teaching and promotion programmes is a method in itself, required byeducation planners.

9. Evaluation
Developing evaluation methods for the effectiveness of bioethics education is urgently required inmany dimensions such as: knowledge, skills and personal values.
There is a need for continued research into appropriate assessment methods for the curriculum, as
well as research into appropriate assessment methods for student learning outcomes and researchon appropriate assessment of practices including student, professional and public attitudes towards
bioethical issues.
Evaluation should be authentic, comparative and ongoing to give a better estimate of the way bioethics
is received in each group.

10. Human capacity building
It is important to raise the awareness within the science community of the importance of the “ethics
of science”. This can be achieved through various measures, including compulsory ethics education
events, such as workshops, conferences, refresher courses and support from parent organizations andagencies such as UNESCO.

11. Networking
We will work towards the expansion of the International Bioethics Education Network initiated in 2004,
and also see the creation of networks linking research into policy as a cornerstone of efforts in all levels,from local to regional. Important points include:• The need to establish and support network partners for the development of bioethics education. These
partners can include many existing associations and could also lead to the development of new forums,

networks and associations where appropriate;• The networks should develop research to have an influence at the policy level;• There is a need to expand the existing regional networks for bioethics education, and improve methods,
delivery and assessment for bioethics education;• The network of teachers needs to be developed inside each country and between different countries;• Networks can support teacher education (pre-service and in-service);• Find more partner schools and universities to enhance capacity of effective bioethics education;• Networks (including NGO’s) can raise community awareness about bioethics;• Gather more cross-cultural data to measure the effectiveness of bioethics education;• Networks can provide workshops for Institutional Review Board (IRB) members;• Through the networks, scientists will be informed about conferences to enable dialogue between
scientists and bioethicists.

12. Recommendations
In addition to the above conclusions, we also address particular recommendations to the following
groups.

• To be involved in promoting bioethics education and to develop methods to document this (such as
check lists);• Continuous exploration of emerging ethical issues in science and technology (e.g., neuroscience,enhancement, biotechnology, nanotechnology, etc);• Inclusive of cultural sensitivities in research;• Bottom-up approach in research;• Embrace hard-to-reach groups in research;• To be fair in publicising research;• To write papers to explain the needs given the situation in each country to various target audiences whoneed to understand the subject more in order to support methods for bioethics education. These groups
include policy makers, media and university faculties, for example;• Take own initiatives to develop activities mentioned above (do not wait for the government or others toact);• Involve the media;• Research how to communicate and how to make consensus between philosophers/ethicists andscientists;• Network with others to encourage sustainable activities.
Recommendations to teachers:• Action started from teachers themselves has been essential for development of the field, and willcontinue to be important for evolution of the subject;• Not to discuss just “Ethics or “Science”, but to integrate (ethics through science);• Avoid personalization in teaching ethics (personal agendas/values), rather empower students to maketheir own decisions;• Construct a classroom atmosphere conducive to bioethics education.
Recommendations to universities:• To establish bioethics departments and centres;• To establish bioethics teaching and learning resources centres;• To give adequate resources to support the activity of the centres;

Asia-Pacific Perspectives on Bioethics Education

Recommendations to researchers:

175• To establish and to provide sustainable support-courses for bioethics education in teacher capacity
building.
Recommendations to governments:• Governments should support these efforts by giving more priority to bioethics education;• To have greater interdepartmental dialogue between different ministries and departments;• To embark upon capacity building for government members (bureaucrats and politicians);• To allocate time in the curriculum;• Allocate funding mechanisms to achieve these goals over a long term period;• Train media, teachers and other groups;• Establish and fund independent bodies (e.g. bioethics committees) that can engage with the community
on bioethics;• Seek contributions to better understand science’s potential contributions cannot be randomly set instone but require adaptive cooperation, intelligence, flexibility and a well developed sense of ethics.

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Recommendations to UNESCO:• In-service teacher education;• Training of media, teachers and other groups;• Newsletter to exchange the information;• Develop curriculum in bioethics;• Develop and share materials and case studies;• Assist in networking and establishing documentation centres;• Continuing to facilitate opportunities for cross-cultural dialogue, networking, research activities andsharing;• Continue to advocate teaching of ethics for science and medical students;• Lobby for the importance of this at the governmental level (national commissions andintergovernmental organizations);• Strengthen the international bioethics education network, and assist in the development of associations.

Discussion and discourse at the conferences account for a significant part of the meetings. They areoften wide-ranging and equally thought-provoking. Excerpts from some of the discussions are, thus,
provided in the following pages. They are identified by the titles of the presentations after when theyoccurred.

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Discussion

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Lindsey Conner (New Zealand) -The Importance of Knowledge
Development in Bioethics Education
Abhik Gupta (India): In fact your study reminds me of another study, where it seems that making young
people environmentally aware - simply giving them information - doesn’t make them environmentally
literate. Do you think a similar situation applies here? For example, we may have ethically aware people
who have a lot of information, but they’re not really ethically literate.
Lindsey Conner (New Zealand): Yes, in fact in this case I would say that they did not even have enoughinformation. So you’re right, yes. Having the information and being aware and then using that
information is a totally different dimension. So on the one hand you may know, but use and action isthat extra dimension that I think was mentioned earlier this morning, too.

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Jothi Rajan (India): Thank you for the nice presentation and your good work on bioethics teaching forhigh school students. Regarding the bioethics education for high school students, I will just ask you
two questions: the curriculum on bioethics for teaching high school students: should it be formal orinformal? Secondly, should the assessment be exam oriented or not exam-oriented?
Lindsey Conner (New Zealand): I will talk about the New Zealand case, because we have had a formal
exam oriented education for bioethics in New Zealand since 1994, and it was mandated as part of thesenior biology curriculums since 1994. We’ve had 11 years of high stakes assessment linked to theteaching of bioethics, and that’s important because without it, I don’t think we would have moved as
far forward as we have done. In their final year high school exam, the essay that the students had towrite was worth 20 per cent of that exam. That is high stakes when you think in terms of the amount ofcontent and how we assess it, just the skills in essay writing alone. But apart from that, yes it is pretty
high stakes. I think it should be like this myself, because of the link with what is assessed tending tobe what is valued. So until you’ve got into your assessment, and until it has that high stakes status, it
doesn’t happen, except by advocates or people who are very committed. This is the national curriculum,
all teachers need to be addressing these issues as it is worth such high marks.

A. Nalini (India): Ethics Education in Medical Curriculum: an Interns
Perspective
Aamir Jafarey (Pakistan): This just goes to show the similarities between the issues that you face withyour interns and residents in India and the ones we face in Pakistan. I did a similar study a couple of years
ago which was published in the Journal of American Bioethics and almost identical issues were identified
by residents. The residents are just at the level above interns who had just finished their internship. The
issues like communication that you mentioned and the fee structure that you mentioned and others
that you mentioned were included. Unfortunately we are not educating our residents, our interns, ourstudents in ethics except for the informal education that is going on by mentoring, but that is ineffective
and unstructured, which is why we are trying to formulate some kind of educational programme. I wasjust wondering whether you plan to see whether your educational strategies are having an effect on
the ethical behaviour of your interns and whether you plan to have a follow up study and see in a year
or two whether that has had an effect?
A. Nalini (India): We have not yet started the formal curriculum as such. So that would be the first step
before we can think about doing analysis.
Jayapaul Azariah (India): Is there any way of abolishing the medical school entry fees, because in India
they pay 150,000 or 200,000 rupees, which if they put it in the bank, they will get more than they earn
as a doctor.
A. Nalini (India): That is true, but in some ways, some of these medical school entry fee institutions are
doing good work, because there are so many younger people who want to become doctors and ourgovernment medical colleges are not able to accommodate all of them. So in that aspect, these institutions
are doing good work or putting an opportunity, but of course I do agree that commercialization of
medical education is to be avoided.

Aamir Jafarey (Pakistan): Can you explain the medical school entry (capitation) fee for us?
A. Nalini (India): Those are the private sector institutions that you pay a huge amount to get into.
Subrata Chattopadhyay (Nepal): Just a quick comment on the capitation fee. I recently joined a capitation
fee college so outside that college in India I can probably comment on that. When the management has
the power to choose 80 per cent of the total intake, and believe me, there are seven days of interviews,
all the carts of the mini-stores and the politicians and the social elites are there, and there is a kindof examination. In the last ten years it has really been moved in the wrong direction I thought, in myopinion.
A. Nalini (India): I would just like to make one comment. Is it the point of the medical profession? Whois having these capitation fee institutions? Not all doctors are running the institutions. It is the common
people that are more so than doctors and as you said, ministers and everybody are coming, so like theremark earlier today: there is moral malaise, not only in the medical profession, it is everywhere.

John Buckeridge (Australia): I have a question about case study three, and whether we need copyright
permission? Obviously the answers you were giving show there were great concerns about informed
consent, but was there any concern about the fact that the obvious thing to do would be to advise thepatient about abnormal genes. Was that any concern at all?
Juraporn Pongwecharak (Thailand): Thank you for your point, actually the point you made was an extra
point that we did not consider. Actually in the case, if you look into the details in the copy which will
be distributed later, actually, the investigator has asked permission for the extra blood collected, for
the AIDS examination as well. In order to match with the DNA they stole from the cervical sample cell,they did not ask her for blood collection, and no safeguard measure beyond the result. I mean, no one
would ever think about informing the patients about when the result comes out and what should bedone next.
John Buckeridge (Australia): Did they not inform the patients about the abnormalities?
Juraporn Pongwecharak (Thailand): They haven’t thought of that so far. May I emphasize this is also
based on the real situation. It doesn’t mean that the case is totally a real one; I made it up, but also based
it on the condition of the real situation.
Dena Hsin-Chen (Taiwan): It is very important to teach ethics though case study material. My question isthat the subject you teach is for graduate students. It means that it should be combined with the abilityof research critique. That we can talk about the case, but for the undergraduate students do you think it
is possible to have case material to teach what is the way to examine?
Juraporn Pongwecharak (Thailand): Yes, and I absolutely agree with our teaching all levels from theschool, including high school, undergraduate studies and graduate study. But in the school I haven’t
thought about the distribution of the case to teach undergraduate students yet. In doing that, I will
have to ask permission from the course organizer for extra time or an extra hour to incorporate such a
topic into the curriculum. So at the moment, it is only included in graduate study and only a three hour
discussion which I think is too little.

Maude Phipps (Malaysia): Bioethics Education in Tertiary Settings:
the UM Experience
Abhik Gupta (India): It’s really very nice to see that you have adopted ELSI concepts in the medical
curriculum. What I would like to know is whether you have adopted similar courses, say for example, inbiotechnology or biological sciences, too.

Asia-Pacific Perspectives on Bioethics Education

Juraporn Pongwecharak (Thailand): Progress Report: Developmentof case study materials

179Maude Phipps (Malaysia): Yes, the lecturers in the faculties of science, which is where the bachelor of
biology and bachelor of biotechnology are taught, have incorporated courses on professional ethics,
morals in science and technology, and also contemporary bioethics.
Karuna Rameshkumar (India): Are the courses that you are referring to in biomedical sciences
undergraduate or postgraduate?
Maude Phipps (Malaysia): This is an undergraduate course, a formal course, which is compulsory forgraduation.
Karuna Rameshkumar (India): The contents of the course looks a little advanced for an undergraduate.
We teach the basics of research ethics at the undergraduate level like integrity and intellectual property
rights. I think it would be very difficult for an undergraduate to understand.

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Maude Phipps (Malaysia): Thank you for your comments, we will take that into consideration. At the
moment it is more exposure, we are really grappling at strings to try and include a lot of things. So
perhaps we might not be testing them on these issues, in fact, when we do our tests, we test themon very general issues. But just the exposure, we are giving them the exposure that these things arearound and one needs to address it. We also have informal post graduates who are invited to attend. So
although it’s not mandatory, we invite them. We invite all of our post graduate students to attend, andhopefully within the next few years it will be made mandatory for them to do so.
Karuna Rameshkumar (India): What is the role of the ethics committee in teaching? Does it have arole?
Maude Phipps (Malaysia): The medical ethics committee reviews research proposals rather thanteaching curricula.

Noritoshi Tanida (Japan): Ethical Views of first-year medical andnursing students in a joint bioethics course
Wang Yanguang (China): I wonder if the joint bioethics course for medical and nursing students is thefirst attempt of this sort in Japan?
Noritoshi Tanida (Japan): Not actually, there may have been some sorts of comparisons in the past inJapan. But there we have observed such kinds of differences, for instance, between medical and nursing
students where it is part of my expectation to see such a result.
Mihaela Serbulea (Romania): I wonder why you used ethical dilemmas from an American background.
There are particular ethical dilemmas referring to Japanese society. Probably the students would be
more sensitive to those?
Noritoshi Tanida (Japan): You mean total truth telling for cancer patients for example. Well yes, but you
see we know the consequences of the cases in the United States for the person in the hospice or on
death row. Since we know the results we used the example for this question.

Aamir Jafarey (Pakistan): Bioethics Education in Pakistan:
Challenges and Prospects
Jothi Rajan (India): I wish to comment that we appreciated your weekly emails regarding the happenings
and also the conferences.
Aamir Jafarey (Pakistan): Glad that you are on our list serve. We have a very enthusiastic secretary andnow, because I have the emails of all of you, you will all be on it.

Anoja Fernando (Sri Lanka): Bioethics teaching in Sri Lanka, thecurrent status
A. Nalini (India): I am just curious to know if you have any training programme for the faculty whoteaches medical ethics?
Anoja Fernando (Sri Lanka): Yes. We have several workshops, each faculty conducts workshops
throughout the year, and we also have external experts who come every year. Also, we do have acontinuing programme of medical teaching for medical teachers.
Jayapaul Azariah (India): I would like to know whether the students write an examination in ethics, andif that mark is included in the final grade?
Anoja Fernando (Sri Lanka): Well, in the different faculties it is different, as I said. For example, in myown faculty, I always include one or two ethics issues. However, they do not actually have to write one
whole essay. It can be part of an essay, or a structured essay question. It is counted for the evaluation,
controlled in marks. Maybe it is not in all faculties, but in my own faculty it is.
Anoja Fernando (Sri Lanka): There has been terrorist activity in the north and the east, so it has been very
difficult to fill the university post in both areas as well as government hospital posts because doctors
don’t like to go and work there.

Anoja Fernando (Sri Lanka): Yes, three out of the six medical faculties are in Colombo.

Daphne Furtado and Karuna Rameshkumar (India): Ethics inParamedical Studies—Mapping a New Agenda
Samantha Pang (China): I have been watching Korean TV dramas, and two dramas were very good inteaching nursing or healthcare ethics. One is “I Dow”, it is about a medical doctor, and another one
which is more about nurses.
Subrata Chattopadhyay (India): Personally I am very happy for your programme. Whenever I go I
prefer your medical college. What I was wondering was giving the scenario of moral dilemmas, as you
mentioned, have you thought of conducting a study of how the students of medical or paramedical
courses are actually practicing ethics in their professional lives after they get out of the college in thesense that the market, the money, the capitation fee, taking bribes, taking commission from the CAT
scans and the MRIs, which is so prevalent in our part of the world. So, teaching ethics is one component.
Getting good marks in the question is another component. We are very happy that we are teaching, but
in reality, what is happening? Have you thought about conducting that kind of study which will give us
the feedback later on?
Karuna Rameshkumar (India): We have been doing these types of lectures for the last forty years. But
after the first twenty years we talked about evaluating the systems, like whether it had been applied. So
what we did was to introduce courses at the internship level and one at the PG level. Our PG level is they
go for two years to rural work and then they come back. So whether they still apply the ethics and what
they learned at the undergraduate levels, we will then evaluate. But beyond that, after that we don’t domonitoring, because after that they don’t come back to us, we don’t have the opportunity to interact.
Only at these two levels we are able to evaluate them after their course.
Daphne Furtado (India): Actually from the paramedical courses we don’t have anybody who has left
college yet. It just started so we can’t really evaluate it, but it’s a very good thing to keep in mind.
M. Selvanayagam (India): Just two days back I saw a documentary from the BBC. An activist in Ethiopia,
a lady, was up against a spurious supply of drugs and the documentary traced the origin of drugs to
India and then to Bombay. I think some medical doctors must be involved in the preparation of drugs.
Do you think it is possible to ban the illegal medical practices? Do you think it is 100 per cent possible

Asia-Pacific Perspectives on Bioethics Education

Mary Rani (India): So most of these schools are located in the capital?

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for doctors to be ethically virtuous?
Daphne Furtado (India): I don’t think so. Actually, nothing is possible like that; you’ve just got to try,
and when I look at the situation I feel so depressed sometimes, but then I see this factor: you know that
there is the possibility of changing an individual and an individual can change the world. At lease you
can make an inroad into the situation, even if you can’t do anything about it, you realize that we are notpreparing them for the real world, we are preparing them for some kind of ethical world, but you cannot
help it.

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Mina Bhardwaj (UK): You mentioned in your presentation that you also teach by using movies and myquestion is related to that, because most of the science fiction movies sometimes are exaggerated
beyond what science at present can do. If you know the movie like “Gattaca”, for example, it is a primeexample of what human life can become, so what can you can see as a road, because it also adds topublic anxiety. So you as an educator, what do you see coming out of teaching those kinds of movies?
Daphne Furtado (India): The problem is that we do not have enough movies in the Indian tradition.
With regard to this there were two movies now - I don’t like using the following ones like Patch Adams
although they’ve got some sense. Many of the students cannot understand the language very well.
We’ve got Hindu movies, two of them which we have just started to with our students. One of themis Munna Bhai MBBS. So this man is an actor who is well known for his ethical role in most films, andnow he’s acting as a medical student and he practices in a medical institution. The second one is Phir
Melenge. “Phir Melenge” has to do with AIDS and an AIDS ethics programme. So I’m hoping, you know,
if we can do something more like this, along our own lines, rather than importing things like “Patch
Adams” or the other ones which come from Scotland. When I look at them I find that it doesn’t makemuch sense in the Indian setting. So that is my appeal. If we could work together, I find so many fromthe Asian region here, if we can work together to advance some movies with themes that would be ofvalidity to our own students it would be a great help.
Jurapon Pongwecharak (Thailand): Can I just add on the comment about the films because I mentioned
in my presentation I use a film, and the name of the film I use is, actually it is a Hollywood film, “Extreme
Measures.” I can say that it is so extreme and I agree with you that sometimes it is not possible in the realsituations, but what I find is interesting is really about the argument each actor makes against or for eachother. I think this is the interesting point. Because the students describe to me that when they listened
to this actor make an argument, they agree and when they turn to listen to the other actor, they think
it is also true as well. So I think this is the way the argument of what was meant. We will know that themovie is quite sometimes extreme at the other end. But I think some of you might have seen “Extreme
Measures” starring Hugh Grant and Gene Hackman. I think it is an interesting film, it is so extreme. Theyuse homeless people as a means to an end, they are used for doing something in medical research, andthey do it secretly as well. So that may be extreme but as I mentioned the argument for or against somepoint was very interesting and we can learn from that.

Dena Hsin-Chen Hsin (Taiwan): To accomplish the Life Education
Mission through Having Bioethics Courses in Medical Universities
Noritoshi Tanida (Japan): I have just one question. I saw in the introduction that you have many
problems with adolescents. It’s the same in Japan; we have a lot of problems with our school children
and adolescents: suicide, violence and so forth. We set out to improve the kind of education, like spiritualand life and death. The Japanese forgot to use life and education rather than life education, is there any
meaning for life education and not life and death education, like the Japanese?
Dena Hsin-Chen Hsin (Taiwan): Yes we also have life and death education in medical schools. But I was
in charge of the class before I went to the Ph.D. programme. Now there is a very professional coursewith topics about hospice and end of life issues. This kind of thing is for their profession. But for life
education, it is hard to let them be a healthy person, an individual with a healthy spirit and healthy life
who is able to help their patient in the future, and to lessen the suicide problem. Regarding the issue ofsuicide I think really it’s too late to have this course in the university level, because in the middle schoolor high school we have faced that problem already. But the faculty’s always the problem in the highschool so we don’t know how to solve the problem.
Peggy Fairbun-Dunlop (Samoa): Is there an increase of suicide and increasing incidents in your country,
and secondly, is it mainly males, females, youth or otherwise?
Dena Hsin-Chen Hsin (Taiwan): Yes it is greatly increasing. Really, it is amazing, it’s the number one
accident as the cause of death in Taiwan. Also for suicide, the age is going down and it’s really worrisome.
Since I lived in Japan, I know they have the same problem, too.
Peggy Fairbun-Dunlop (Samoa): Is there a gender bias?
Dena Hsin-Chen Hsin (Taiwan): It’s not so different.
Subrata Chattopadhyay (Nepal): Regarding suicide and violence, there have been studies which haveshow that Asian Americans, compared to Americans, have lower incidents of violence and suicide
because of their family values and all these factors. I was wondering if you have considered about theirreligious belief or spiritual inclination as a factor contributing to or maybe associated with, you know,
the risk of violence or suicide?

Camille: I feel very strongly about the question of suicide, I know it’s not, perhaps, too much into the
topic of this meeting. But as there are so many people here, engaged in this kind of professional work,
my experience with this is threefold. Number one: young people today are bored. When I hear the worldboredom, I think that is a red light because it means a loss of interest in life, inability to concentrate. I’m
thinking, I mean maybe computers have something to do with it. Maybe the inability to focus attention
which it is not a disease, its being treated like a disease, which is quite wrong. One needs to try andhelp young people to experience what it is like to actually do something, finish it, and feel good about
themselves. That’s number one. Number two is that young people have a very vivid imagination, andwhen you hear someone talking about asking students what they would do if they only have one week
to live, I’m sorry, I don’t think this is a good idea. When you get mature enough to deal with dying
patients, you have to have quite a lot of insight, how to help them to be peaceful. Thirdly, with thisparent pressure, and this whole idea of doing well at school and if you’re no good, and I think it’s whatneeds to get back to basics and I think that about vocational education and people using their skills
and not just paper degrees and there are no prospects in life. Lastly, for all educators here, education is
not just about getting a degree and working in what you’re going to have a degree in. It’s a much wider
thing and I think bioethics can go a long way towards helping us to remember that, thank you. If you aregoing to counsel these young people I think you need to learn how to detect early warning signs, andthis is something which is very, very absent and training most counsellors don’t really appreciate. You
have to learn to listen. Once you learn to listen I think you can help these kids.
Dena Hsin-Chen Hsin (Taiwan): I totally agree with you and I think that it is very important when you
know something about life then you will appreciate and value your own life.

Heiko Ulrich Zude (Germany): Biomedical Ethics Education in PostCommunist Eastern Germany
Aamir Jafarey (Pakistan): I may be completely wrong in this, but is there a similarity in the views ofeuthanasia between former East Germany and those prevailing today in the Netherlands. Althoughideologically they are completely different countries but their views on euthanasia seem to be somewhat
similar, and if so, why is that?
Heiko Ulrich Zude (Germany): In fact they are quite similar, but only in the fact. The motivation to votefor euthanasia on demand is totally different. I think in the Netherlands, you have a very strong liberal
culture and therefore the value of autonomy and self determination is arranged higher than in Eastern

Asia-Pacific Perspectives on Bioethics Education

Dena Hsin-Chen Hsin (Taiwan): In Taiwanese society, religion is not very important. We have somevalue systems like Confucianism and Buddhism and Taoism. For the young people it is not so. But someyoung people have new religions, but usually it’s not so popular. So it is not easy to let them solve theproblematic issues through religion.

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Germany. I think the difference is, in Eastern Germany you have no religious culture anymore. We havetowns with only three percent Christians, or religious people. We have 97 per cent atheism. In sometowns, not overall in Eastern Germany, and therefore there is a lack, I guess, to care for the value of life if
it is not anymore a function in society. But I think the main difference is in the liberal culture, the liberal
tradition and motivation. In fact, it is very similar.
Irina Pollard (Australia): Might there be another explanation perhaps? I find it hard to believe that in avery short period of time, that the East and West have changed through social conditioning. In the East
perhaps there aren’t any of the opportunities of having contraception for example, as there are available
in the west. The autonomy, the wish to be making your own decisions is there equally strongly, except
there isn’t the back up of the businesses, of providing contraception. Providing education at the schoollevel saying that reproduction is a privilege and not a right and with that privilege go to have informed
pregnancies, those sort of attitudes, rather than a more complicated social conditioning in 20, 30, 40
years?
Heiko Ulrich Zude (Germany): So you think 50 years is not enough time to change.
Irina Pollard (Australia): I don’t think so, no.
Heiko Ulrich Zude (Germany): Today you have in Eastern Germany the same standards as Western
Germany.

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Irina Pollard (Australia): So contraceptives are equally available on both sides?
Heiko Ulrich Zude (Germany):Yes, of course.
Irina Pollard (Australia): And education about contraception? And being open and speaking about it?
Heiko Ulrich Zude (Germany): It’s all the same. You have few differences, institutional, organizational andthe universities are even more modern than in Western Germany today, because everything was built
new. And if you go there in Eastern Germany you see especially in the main towns, you have very new
towns and every building is just built up ten years ago.
Irina Pollard (Australia): In which case, if society can be fundamentally changed in a very short period oftime, maybe there is hope for including, say, other environmental things, so maybe we are much more
flexible than it seems.
Jeong-Ro Young (South Korea): If my understanding is correct, I understand that in Germany there is avery strong intellectual tradition of the ontological viewpoint in bioethics. You have already given us
the information that the former East German societies are in the process of being built anew over the
past decade. However, I really wonder why the medical ethics syllabus has been modelled after the
British model instead of the ontologically based German model? Is there any difference? I wonder who
has been in charge of organizing the syllabus and the medical ethics course.
Heiko Ulrich Zude (Germany): Those people were mainly physicians and I often think in Germany
everything is good that comes from the West. That means the USA and the United Kingdom, andtherefore, people say why not look there if you have to create a new one? You can copy it, and mostdifferences or ethics, between Kant and John Stuart Mill, for example, that doesn’t appeal to thosephysicians who create the syllabus. I am not a physician, I am a philosopher and I studied theology,
I know it. I am very critical about this because the point you mentioned is not reflected in this book,and not in the syllabus. That’s a problem I think, because the concept of autonomy is totally different
if you come from the tradition and the culture of the USA, you have Bentham and John Stuart Mill andutilitarianism or if you come from Europe and you have Immanuel Kant with his concept, but it is notreflected.
Samantha Pang (Hong Kong): I need to thank you for your analysis of the East and West German
situation, because I have been doing a study in Hong Kong and also mainland China and actually I makevery similar observations regarding attitudes between euthanasia and abortion. Actually your analysis
threw light to me about how to make sense of why there are differences and now I will be thinking of

these issues in a wider sense.
Heiko Ulrich Zude (Germany): I have learned from the Chinese medical ethics draft to get thisinterpretation, so look in there and you’ll see where the problems are located.
Wang Yanguang (China): I just know from your talk that they started courses in 2002 to teach ethics
for medical practice, and for medical ethics to begin to absorb into medical education and also to the
medical teaching. What I want to know is what happened before 2000?
Heiko Ulrich Zude (Germany): Nothing about real ethics. What happened was pure paternalism, I guess,because the physician knows best, and the structure of the education in medicine is very hierarchical.
You’ve got the C4 professor and then you’ve got C3 professor and then you’ve got the overall physician
and the normal physician and then you’ve got the students of medicine. What he above tells is the truth,
and the impact to install ethics in the medical curriculum did not come from the physicians themselves.
It was an impact that came from society and from theologians and from philosophers.

Chanreoun Pa (Cambodia): Thank you very much for an interesting presentation on the way ofteaching students about the moral values. But in the meantime, according to my observation, I think
the teenagers, at least in the present time, are sensitive, at least in terms of getting influenced fromconsumerism and the mass media that you mentioned. So my question is, what are the approaches thatyou have conducted in providing fulfilling the students’ needs in order to see the value of moral values
education?
Senthil Kumaran (India): I think we can introduce some fair websites.
Jothi Rajan (India): Thanks for a nice question. Actually, there is team evaluation, as far as my college isconcerned. Team members are provided with a certain curricula or syllabus that should be taught orshould be practiced and we also go through the various cinemas which are in the town as well as thedifferent websites which are in vogue. Accordingly, we just advise them and also we give them some
opportunity whenever possible, to access the Internet because ours is a rural institution located in arural setup and Internet access is a bit remote to us.
Mary Rani (India): In India we also have this media education. In the schools we teach them, as a part ofcurriculum, we talk to students about sex education especially and also media education. We view a film
and them we lead them into a discussion - what are the scenes to be taken and what is not realistic. The
students prefer this type of media education. Also we have this “enviro-club,” where we inculcate thisenvironmental awareness to the students, so these are the two important practices in India.

M. Selvanayagam (India): Environmental Education and Eco-EthicsCurrent Trends in Education
Jasdev Rai (UK): One of the remarkable things about village life in India traditionally was there wasrecycling of everything. I have been to India and I have met people in the cities who have never been tovillages. This is in Punjab. I am just wondering whether you take student trips to see the rural situation.
M. Selvananayagami (India): We don’t take the students to the villages; we take them to a neighbourhood
where we are allowed several day trips. We show the students how to separate the solid waste or
recyclable or biodegradable/non- biodegradable waste and also the students improvising and all thesethings are done without villages. We are a reach-out programme.

Asia-Pacific Perspectives on Bioethics Education

Senthil Kumaran (India): Teaching moral values for high school
students- Indian context

185Michael A. Jothi Rajan (India): Value Education: A Treasure of a
NationZhen Grace Zheng (China): I am just going to make some comments. I loved this speech and thank you
for your passion in saying that values can be learned in real life. As you said the love from the motheris the first thing a child wants and you also said we can fly freely like birds, and we can dance freely likeocean waves. It makes me think that maybe the practice of bioethics education should not be only
confined to the expert level and we can invite some other participants.

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Charn Mayot (Thailand): I agree with you that value education or even ethics education is not only what
we said or what we thought, but it should be something like what we live. And you accommodate somesocial activities to the causes. I have that experience, do you ever come across the experience of somestudents who might come from a certain family background who feel very negative to this activity andthey sometimes ask the questions: Why do they have to do it? They don’t find any necessity to go out
and see things different, and something that maybe they did not want to see. In this case, how do you
deal with them and persuade them that at least it is a way in which they can experience and expand
their world view. In some cases, it may be useful and it might change their attitude towards others.
Michael A. Jothi Rajan (India): This situation did not arise in my case because in my college all thestudents are coming from average and below average families. They are below the poverty line. Hence,
we give more preference for the poor so that education is an option for the poor. When a student comesto the classroom, from his face we all know - we can predict whether they have eaten breakfast or not.
Maybe if I come across this situation in the future, I will have to think how to answer it.

Ester Estrella M. Abito, Milarosa Librea and MaryAnn Chen Ng(Philippines): Bioethics Education Trials in the Philippines
Charn Mayot (Thailand): Can you share the experience of your conducting bioethics in high school. I
have experience in conducting ethics classes at university and for students with diverse backgrounds.
Normally we concentrate on how to reason and moral reasoning, but for example, in my country, moral
education normally emphasizes the cultivation of the values that we think are desirable for our society.
In your context, how do you blend these two concepts in your classes? Because it seems like the catholiccommunity has some values that they want to implement into the ethics classes. Especially in this issue,
there are so many points and actually there are different ideas even in communities of the scholars, evenin the communities of the catholic scholars themselves.
MaryAnn Chen Ng (Philippines): That’s a very good question. Actually, in this case it’s a Jesuit school, andthe biology teachers, although they are given a certain amount of academic freedom in the classroom,cannot veer very far from what the ideals of the school are, that is, Catholic. So in that sense, they haveto reinterpret the chapters in the light of their identity, and I think that’s a strong way of dealing with
it from their part, so they are always in the, I would say, constant modification of certain things, in thesense that they cannot go very far away from who they are.
Samantha Pang (Hong Kong): I am very interested to know you have bioethics in biology classes. My
question is, what is the way of knowing or the way of attaining knowledge in biology, and the way ofgetting into moral reasoning as bioethics seems to be quite different to me based on my experience. I
have a nursing background and also study philosophy, so when I start my teaching I am given a class onteaching typical physiology. Then I give a class on teaching theories of knowledge and human natureand then when I go to two classes, I find that I have to shift my mind, otherwise I cannot go into the otherdiscipline. This impacts the understanding of the students who understand that kind of knowledge. So
my question actually is: why not take bioethics as a separate class and why integrate into the biology
class?
MaryAnn Chen Ng (Philippines): Basically when we approached them they said that we choose tointegrate it into the biology classes. So it’s their choice to integrate it into biology, but what we do,for example, is we first get into the scientific technical stuff and then maybe, let’s say in a one hourclass period they would spend about 45 minutes teaching the science of the topic and then the last

15 minutes will be used for some bioethical applications. Then also they use it very much like when it
comes to homework, so they have lots of essays and basically the students can write their opinions athome and just give it up at the end of the day. Actually, during the end of the first year they were also
thinking, “let’s expand to other areas,” let’s say religion or social science but as of now that has not been
implemented completely. So in a way, it was very logistical, it is very easy to introduce in the context ofthe biology curriculum.
Jothi Rajan (India): I would like to tell one thing, that the Jesuits that are in the Catholic Church arequite advanced in the sense that I have found that they will accept bioethics as a separate curriculumin the whole college. Because now, they don’t have any kind of inhibition, so is to say, now Jesuits havelaws in the theology of liberation, so there is no problem involved whether to include bioethics as acomponent. So it will be included as a separate discipline and while the professor is there, he can also
give his comments.

MaryAnn Chen Ng (Philippines): This connects to the issue of assessment and evaluation. The firstquestion is: if you teach bioethics, are you supposed to give it as a question in exams and if you give it
as a question in exams, then the entire paradigm becomes different? So the decision right now of theschool is basically not to grade it. Because they don’t want to say this is what the correct answer shouldbe, or this is the incorrect answer. So in this sense there is no pressure because it is not graded. But there
is a tendency though, to smile upon the train of thought which is in line with the school’s philosophy,
rather than those which are not really the same as what they think is ethical. But I don’t know if you canactually totally ignore that factor.

Duang-Kamol Charptrasert (Thailand): Computer Self-Efficacy andstudent-centred Learning in a Thai Secondary School
Jeong-Ro Yoon (South Korea): Thank you very much for a thought provoking presentation. My questionis very simple, could you specify the computer related skill to raise the computer self efficacy in addition
to English you mentioned, if my understanding is correct?
Duang-Kamol Charptrasert (Thailand): I’m afraid that in this study, the computer-related skill was
specified by me. I include only those variables that I thought might be related to self-efficacy. I thinktyping today may be related to self-efficacy. I also look at maths skills. I compare students whose major
is in maths and science as opposed to those who are majoring in social sciences and humanities. There
are differences among them; those who are maths and science majors process higher computer selfefficacy than the rest. So I have to think more about those skills. But I also include some other variablesin the past, like some psychological related variable, but not the skills, per se. I look at typing and maths
skills and the need for communication which involves the use of logic and also the language skills.
Lindsey Conner (New Zealand): I’d just like to make a comment too, around the use of the internet forinvestigating bioethics issues, because one of the things that becomes important is: how to you assess
the bias, or how do you critically evaluate the information that you are getting from the internet. So I
don’t know, would you like to comment on that because it applies to all Internet use but it particularly
applies to bioethics. How do we help students to understand that some information might be biased?
Duang-Kamol Charptrasert (Thailand): I am also doing work and research in media literacy as a whole,and that includes internet literacy as well. I don’t know, I try to develop the students’ critical ability,
like when I teach a class, I always ask them questions. So my students don’t like to talk in class because
whoever started talking I will call them and ask questions. I think that developing critical ability isvery important, like whenever I ask them about a new study that appears, or even when I tell themsomething, I always tell them that they don’t have to believe me, or: “You don’t have to think the way I
am, this is just my opinion.”Asia-Pacific Perspectives on Bioethics Education

D.S. Sheriff (India): In a very highly competitive and crowded curriculum, particularly at the plus twolevels, when the schools are only interested in getting the results, how do you find a space for teachingbioethics?

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D.S. Sheriff (India): Do you tell your students the scientific information that is found on the Internet issometimes misleading?
Duang-Kamol Charptrasert (Thailand): No, I don’t say that, but I encourage them to evaluate all
information. I mean they don’t have to use this information. I teach them the skills about how scientificknowledge comes about, what people do in coming up with scientific knowledge. They can use theirknowledge about their research methodology to evaluate information. They can question. I always tellthem you don’t have to believe everyone, you can use your knowledge of research methodology tojudge and to evaluate incoming information. You don’t have to believe them because they are foreigners
or they are Thais, or because they are university professors. I mean they have to evaluate information
themselves. I teach them the tools too.

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Asia-Pacific Perspectives on Bioethics Education

Liping Wang (China): This Year’s Flowers are Redder than Last Yeara Brief Introduction of the Bioethics Project in the High School
Affiliated to Beijing Normal University in the Past Two Years
Irene Taafaki (Marshall Islands): I’ll preface this question with a comment: I am originally from the West,and I’m here in the East, and I live in the South, so perhaps we can meet at some level. Now it’s a very
unfortunate though in this day and age that we can’t meet. I’m interested because you had the firstreference I’ve heard in all of the discourse so far, on parents. The role of parents in ethical education has
not come up yet, and I wonder how the responses are with the parents? You say that they take it home
and talk to their parents, whether their parents actually bring issues up. Because I would think this isvery much at the heart of preparing the minds and the hearts of students to the debates that you’re
fostering in the classroom that really look excellent.
Liping Wang (China): Family education is a very important part of lifelong development of teenagers.

Jianzhi Li (China): To Treasure your Life, Refuse Drugs
Samantha Pang (Hong Kong): I think this will be very useful and thoughtful for the students to handle
the drug situation. My concern is more about the correct conception of drugs. Heroine and morphine
actually are used quite liberally in the imperative care setting as a kind of pain killer. I attended the AsianPacific hospice conference which was held in Seoul in May 2004 and there is a survey coming out thatin the Asian region the use of morphine for controlling of pain is much less because of the conceptionthat this is an evil drug and so it cannot be used. Even for the general public they think that this is an“evil” drug. At the same time, the pain that is being suffered by these people is considerable. So there isa concern about how to correct the view of looking at morphine and heroine as pain killers. So I’m justwondering, this is really a very good programme to teach the students about the correct conception of
drug abuse but at the same time I do hope that there is some positive ways of introducing that the drug
is therapeutic under good medical guidance for the treatment of diseases, particularly for people whoare already at the end of the life stage.
Jianzhi Li (China): Let’s not make a mistake between drugs and medicine. Many drugs have a medical
function, however, once they are abused, or similarly, if they are not used for medical treatment, they
will be drugs. Meanwhile, the characteristics of drugs are that they are addictive and illegal.
Irene Taafaki (Marshall Islands): So I agree with the previous comment. There is a big difference between
drug use and drug abuse, and I think the grim reaper approach isn’t going to stop people fromexperimenting. Perhaps there should be a moderation in educating people as to what the drugs do.
Only approximately 10 per cent of the population has a predisposition to addiction. So most people do
not become addicted. I’m reminded of a publication where burns victims, 10,000 people, were given
morphine in hospital against pain. Medically, all of these people were addicted, but there were only 16
people who abused drugs afterwards because everyone always thought it was just part of the curing
procedure.
Jianzhi Li (China): I know some case about how to realize the pain of the patient, but the patient has anaddiction. I don’t know whether or not there are a lot of related cases in China. It’s a problem that weall should consider.
Heiko Zude (Germany): I am very sceptical about your presentation, because what you tell the students
or the scholars is do this and don’t do that. So my question is: do you really think that ethics means to tellpeople what they should do and what they should not do? Is this your concept of ethics?
Jianzhi Li (China): I think that should be necessary. I think it does make sense that we do apply thebioethical issues into our school. Here I would like to give you a practical example. Many students saythat drug abusers deserve to die. After taking the training they learn that drug abusers, when they
are addicted, they are a kind of psychopath from a medical perspective. They are not able to control
their behaviour, thus we should consider whether the drug abusers should be punished when they
are addicted. Therefore, this article makes students think more scientifically. There are many similar
articles. These articles are meant to provide a possible solution for them. However, this discussion andintrospection for those matters help us think of our behaviour to be a choice later.

Aamir Jafarey (Pakistan): Thank you very much for a good presentation on a very important topic. What
I wanted to understand is the views expressed by your participants in the study and your own views
about the issue of organ transplant tourism that is taking place in the developing world. Especially,
people from the developed world are going over to developing countries - such as China, Pakistan andIndia - but people from developed countries go to developing countries to procure organs, kidneys
primarily from poor patients, from sellers and then go back home. What are your views and what are theviews of the participants in the study?
Zhen Grace Zheng (China, translated): We think this is not in accordance with ethics and it is illegal tobuy human organs privately, and we are sure against these kinds of things in our class. Someone putin this mornings’ presentation that sometimes there is no answer. The only answer that we could give
students is to give them the opportunities to think, but for this question we hope for this question
we do have an answer. The answer is that these things are illegal and we should try to set rules andregulations to prohibit these kinds of things.
Yanguang Wang (China): From your talk, your class is about citizen education, not about ethics. Because
in your talk you tell students what is right and what is wrong, so maybe your teaching isn’t this andmaybe you have something else to talk to us. For example about drug use - the bioethics question
should go deeper. Not only “leave out drugs.” The proper question is another. For example, do you think
the drug user who is an addicted patient sensing all this, can be told how to prevent HIV? How to treatsuch person who is addicted to drugs? In China now we have a programme, we give drug users who are
addicted methadone. So it’s not just about what is illegal, it’s about another bioethical question that you
should raise with students and allow them to think, and not tell them you should do this because life isgood, it’s just a low level.
Zhen Grace Zheng (China, translated): You say we are dealing at a pretty low level, because we are tellingthe students what to do and what not to do and bioethics should go deeper. We agree that bioethics
should go deeper, and not to tell students what to do and what not to do. But this is what we are doingin our class and we are giving students some pictures, some visual materials and also we give themsome reading materials, some examples from real life, then we give them alternatives to discuss. Our
target audience is high school students, so bioethics is a kind of theory only that the students cannot
learn. So we should provide them with some vivid illustrations, vivid examples, and then they will wantto think and form their opinions fully in our class.
Yanguang Wang (China): I think that students are teenagers, that high technology they should know
from the mass media. So I am sensing something about the bioethical principles is easy to teach them,so if you lead the student step by step they can learn more.
Zhen Grace Zheng (China, translated): We do understand and we will think about that, but the basic
principles of bioethics are very important. For example, beneficial and do no harm, and things like that.

Asia-Pacific Perspectives on Bioethics Education

Yuan Yu (China): Organ Transplant and Organ Donation

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Probably, the best way to learn is first of all you should accumulate something, and you should have somebasic information and basic knowledge. If you accumulate enough knowledge, enough backgroundinformation, with that we can start thinking. We will take your suggestion into consideration and dosome change probably in our later courses. Thank you very much.

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Jayapaul Azariah (India): Responses to Bioethics Education acrossCultures- a survey to assess the bioethical need across THE social
strata in Tamil Nadu, India
Lindsey Conner (New Zealand): Thank you very much for making a very pertinent point because you areright, because context and relevancy are so important when we’re learning in bioethics and I think thisbrings us to something I was going to bring up in the text book meeting. But what it means is that for us
to develop resources we need to think about the purpose of those resources and how they’re going to
be used. So my take on the resources is that they are there as a source bank and that teachers would be
able to pick and choose which ones they may find useful for their students. But I’m also very aware thatin some countries, it’s important to have a text book you can use from page one to page 50, you know,
and work through and I am not sure that that is the purpose of the resource that is being produced. So,
we just need to keep in mind that different countries seek text resources for different purposes. Perhaps,
the activities that we develop are not necessarily supposed to be delivered one after the other, or allof them or any one of them, but that we would have the chance to select which ones we might use.
Another useful thing to think about it is having the resources available electronically so that you can
modify them for your own purposes or make them more relevant to your own context. And that is theadvantage of having an electronic resource, of course.
Jayapaul Azariah (India): In the Indian context, the moment it is said that this subject will not count for
the final examination, they laugh in the class, they laugh at the examination.
D.S. Sheriff: I think the very idea of having a text book is to make people aware that there is a resourceof information, you know, if they want to start a course. So that serves the purpose of the text bookproject. Number two, for example if you want the subject to be taken very seriously, and considered at
the university level, first of all you have to create a group of teachers who are trained in bioethics. So
this teaching has to first make the students aware that it is a subject. Then train those students to takeup where the majors could be life sciences or the humanities, one of the ancillary subjects could bebioethics. Or you can have the reverse; you can have bioethics as the major subject. What I am saying
is it’s possible nowadays we have new universities, very different from established universities and it isvery easy to introduce new subjects to be introduced in different universities, and in those universities
if you could approach this, it could work quite well. I know it is very difficult because many of us learned
people do not know what the bioethical principles are. Because first, I think, you have to make people
aware, and I think this project will definitely make people aware of what the problems are, what the
ethical principles are that one must relay from the laypeople to the teachers.
Jayapaul Azariah (India): The bind is that if you are comparing India and another country, any new
development in other countries takes about 20 years to take root in India, except in terms of technology.
In terms of technology we are ahead of other developed countries. But in other areas, not only are
we talking about sustainable development that was developed in the 1980s, so it took so many years
for us to see because of a supreme court order which made it mandatory on every student to study
environmental ethics, environmental biology, and sustainable development. So I suggest to Darryl to
use the UNESCO office and see that the Supreme Court gives an order that bioethics should be studied
by every student.

Subrata Chattopadhyay (Nepal): An Earnest Appeal: We NeedSpirituality in Medical Education
Samantha Pang (Hong Kong): I am wondering in an Indian perspective, how spirituality is contributing
to medical ethics in the preparation of healthcare professionals. My question is actually while you wereAnotherreasonis that,fromtheChinesetheory,for example,
a person
begins after
birth,
presenting,
I thought
about
Hong Kong
scenario.
We areina Confucianism,very secular society
and actuallyat present
after
delivery,so there aresohow
manywereasons
supportthis stance.
we arestill struggling
withshouldtodefine
spirituality.
We still cannot define it, because themajority of Hong Kong people do not have religion as such. It is only the minority who have Christianbeliefs and some ancestor worship. So I have a question as to whether spirituality is related to medical
ethics and if medical ethics can readily address the issues about preparing compassionate caring
professionals. Maybe more specifically, the reality that you presented - is it a very Indian perspective oris it applied to other cultures as well? Because it seems so applicable to the Hong Kong scenario.

D.S. Sheriff (India): Perspective on the Role of Sex Education in the
Changing Cultural Scenario and Psyche of Indian Personae in the 21st
century
Irina Pollard (Australia): Just a short comment about gayness - it’s not really a matter of choice, it’s abiological grouping, the same as transsexuals and heterosexuality and homosexuality, it’s part of thecontinuum of human sexuality and it’s based in biology.
D.S. Sheriff (India): But for a teenager it appears very much that many have not been exposed to thisinformation. For example if they are asking you, they will not be able to decide whether it is biological,
or if there is a genetic disposition to such behaviour.

Christophe Kwami Dikenou (Togo): The Teaching of the Ethics ofScience and Technologies
Miyako Takagi (Japan): Could you make a comment on the relationship between international bioethics
laws and medical experiments in Africa?
Christophe Kwami Dikenou (Togo): We can make experiments in Africa, but these experiments should
be made in respect to international bioethics laws.
Noritoshi Tanida (Japan): I think your talk is very important particularly for pan-American bioethics
initiatives. I think everyone knows as I have mentioned before that this dominance of North American
bioethics caused lots of problems in health in African countries. I’d like to raise one example, a vaccinethat was developed for children in African and Asian countries but because of that tiny side effect, thatvaccine was withdrawn, and now a new vaccination is coming out. But during this time, roughly infive or six years, many children in Africa and Asia died because of this imperialism of North American
bioethics, so I want to praise the initiative by you in Africa.

Asia-Pacific Perspectives on Bioethics Education

Subrata Chattopadhyay (Nepal): I believe it applies to everyone, the studies I have included are
conducted in the USA, but there are studies in other parts of the world as well. I believe it applies to every
culture and every religion, and the state. The particularities and the specifics need to be addressed in thespecific given scenario. I cannot say what should be done in Hong Kong. You are in a better position to
say how to incorporate the emotional and spiritual components of ethics. I am not just saying ethics; it is
ethics, philosophy, history of medicine, all need to be incorporated at least to some extent. I was visitingan ethical meeting in Germany and they actually say that history and philosophy of medicine needs tobe taught to the students. From 2004, they started competency classes for the medical students that
ethics, history and the philosophy of medicine are taught together, so I guess it will differ from one
setting to another setting.

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About the Contributors

Ester Estrella M. Abito is a biology teacher at the Ateneo de Manila High School, Loyola Heights,
Quezon City in the Philippines. (emabito_ethics@yahoo.com)
Syeda Kauser Ali is working at the Centre of Biomedical Ethics and Culture, , Sindh Institute of Urology
and Transplantation, Karachi, Pakistan.
Atsushi Asai is Professor of Bioethics in the Faculty of Medical and Pharmaceutical Sciences, atKumamoto University, Kumamoto, Japan. (aasai@kumamoto-u.ac.jp)
Jayapaul Azariah is Founder President of the All India Bioethics Association, Chennai, India. He iscurrently President of the Asian Bioethics Association. (jazaiah@yahoo.com)
Preethi Azariah is a member of the All India Bioethics Association, Chennai, India.
Subrata Chattopadhyay is Professor of Physiology, Maharajah’s Institute of Medical Sciences, Nellimarla,
Vizianagaram, in Andhra Pradesh state, India (linkdrsc@yahoo.com)
Lindsey Conner is a Principal Lecturer, College of Education, School of Sciences and Physical Education,
University of Canterbury, New Zealand (lindsey.conner@canterbury.ac.nz)

Anoja Fernando is Professor in the Faculty of Medicine, University of Ruhuna, Sri Lanka. She is Chair of
the Sri Lankan National Bioethics Committee. (anojaf@yahoo.com)
Jinhua Fu is a biology teacher at the High School Affiliated to Beijing Normal University, Beijing, China(xinyue2468@sina.com)
Sr. Daphne Furtado is an ethicist based in Religious of the Sacred Heart, Patna, Bihar, India. (dviveka@
gmail.com)
Dena Hsin Hsin-Chen is associate professor of bioethics at China Medical University, Taichung, Taiwan,
China. (hchsin@hotmail.com)
Aamir M. Jafarey is Assistant Professor at the Centre of Biomedical Ethics and Culture, Sindh Institute of
Urology and Transplantation, Karachi, Pakistan. (aamirjafarey@gmail.com)
J. Agnes Jecintha is a science teacher at Sirumalar Girls’ Higher Secondary School, Nagamalai, Madurai,
India.
Siriporn Krittathanmakul is in the Department of Clinical Pharmacy, Faculty of Pharmaceutical Science,Prince of Songkla University, Songkla, Thailand.
Karuna Ramesh Kumar is Professor and Head Department of Clinical Pathology, St. John’s Medical College
Hospital at St. John’s Medical College, Bangalore, India. (karunark@yahoo.com)
P. Senthil Kumaran is a Ph.D. student in Tamil Studies at Pondicherry University, Pondicherry, India.
(psnthlkmrn@yahoo.com)
V. Fragrance Latha is a chemistry teacher at the Government Higher Secondary School, Thiruvadavur,
Madurai, India.
JianZhi Li is a biology teacher at the High School Affiliated to Beijing Normal University, Beijing, China.
(li_jianzhi@hotmail.com)
Milarosa Librea is a biology teacher at the Ateneo de Manila High School, Loyola Heights, Quezon Cityin the Philippines.
Darryl Macer is Regional Adviser in Social and Human Sciences for Asia and the Pacific, at the Regional
Unit for Social and Human Sciences in Asia and the Pacific (RUSHSAP), UNESCO Bangkok, Thailand.
(d.macer@unescobkk.org)

Asia-Pacific Perspectives on Bioethics Education

Kwami Christophe Dikenou is Chief of the Department of Philosophy, and Chief of Laboratory of Ethics
Universitate de Lome, Togo. He is currently based in UNESCO Dakar, Senegal. (kdikenou@yahoo.fr)

193

T. Mathavan is a lecturer in the Department of Physics, Madurai Kamaraj University and at NMSSVN
College, Nagamalai, Madurai, India.
Inayat U. Memon is Senior Pathologist at Liaquat University Hospital, Hyderabad, Sindh, Pakistan.
(memon.inayat@gmail.com)
Shigeo Nagaoka is a Professor in the Faculty of Education and Human Sciences, Niigata University,
Niigata, Japan. (shigeo@ed.niigata-u.ac.jp)
A. Nalini is Professor and head of the Department of Curriculum Development at the Tamil Nadu Dr.
M.G.R. Medical University, Chennai, India (nalinianna@yahoo.com)
MaryAnn Chen Ng is from the Philippines but currently living in California, USA. (maryannchenng@
yahoo.com)
Maude Phipps is a lecturer in the Department of Molecular Medicine, Faculty of Medicine, the Universityof Malaya, Kuala Lumpur, Malaysia. (maudephipps@yahoo.co.uk)
Juraporn Pongwecharak is a lecturer in the Department of Clinical Pharmacy, Faculty of Pharmaceutical
Science, Prince of Songkla University, Songkla, Thailand. (pjurapor@pharmacy.psu.ac.th)

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Asia-Pacific Perspectives on Bioethics Education

Michael Anjello Jothi Rajan is a lecturer in the School of Physics, Madurai Kamaraj University, Madurai,
India, and Teacher cum Researcher in Physics, Arul Anandar College, Karumathur, Madurai District, Tamil
Nadu, India. (anjellojothi@yahoo.com)
M. Selvanayagam is Director, Loyola Institute of Frontier Energy (LIFE), Loyola College, Nungambakkam,
Chennai, India. (drmssel@yahoo.co.in)
D. S. Sheriff is a professor at Jubilee Mission Medical College and Research Institute, Kerala, India.
(dhastagir@yahoo.ca)
Shinryo N. Shinagawa is emeritus Professor at Hirosaki University School of Medicine, Hirosaki, Japan.
(shinryo@smile.ocn.ne.jp)
G. Srivinas is faculty at the Tamil Nadu Dr. M.G.R. Medical University, Chennai, India.
Atsushi Tajima is Professor at the Agricultural and Forestry Research Centre, University of Tsukuba,
Tsukuba Science City, Ibaraki, Japan. (tajima@sakura.cc.tsukuba.ac.jp)
Noritoshi Tanida is Professor of Bioethics at Yamaguchi University School of Medicine, Yamaguchi,
Japan. (tanida@yamaguchi-u.ac.jp)
Miki Tanoue is in the Department of Nursing, School of Health Sciences, Faculty of Medicine, Kumamoto
University, Kumamoto, Japan. (mikitanoue@hs.kumamoto-u.ac.jp)
Arockiam Thaddeus is a zoology lecturer at the Jayaraj Annapackiam College for Women, Periyakulam,
India. (arockiamt@yahoo.co.in)
Tomoaki Tsuchida is Professor in the School of Human Sciences and the Consolidated Research Institutefor Advanced Science and Medical Care,, Waseda University, Tokorozawa City, Saitama Prefecture, Japan.
(ttsuchida@waseda.jp)
Chutatip Umavijani is Associate Professor and head of the Department of Philosophy, Thammasat
University, Bangkok, Thailand. (chujid@gmail.com)
Ms. Yasmin Wajahat is a specialist of obstetrics and gynaecology at Sobhraj Maternity Hospitalin Karachi, and at the Centre of Biomedical Ethics and Culture, at the Sindh Institute of Urology andTransplantation, Karachi, Pakistan. (ywajahat@gmail.com)
Liping Wang is Deputy Principal of the High School Affiliated to Beijing Normal University in Beijing,
China.

Francis P. Xavier is at the Loyola Institute of Frontier Energy (LIFE), Loyola College, Nungambakkam,
Chennai, India.
Yuan Yu is a biology teacher at the High School Affiliated to Beijing Normal University, Beijing, China.

Asia-Pacific Perspectives on Bioethics Education

Heiko Ulrich Zude is faculty at the Lehrstuhl Angewandte Ethik at the Friedrich-Schiller-University in
Jena, Germany. (heiko.zude@uni-jena.de)

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