Metadata of the chapter that will be visualized online
Chapter Title

Oceania

Copyright Year2013

Copyright Holder

Springer Science+Business Media Dordrecht

Corresponding Author

Family Name

Macer

Particle
Given Name

DarrylSuffix

Abstract

Organization/University

Eubios Ethics Institute

City

Christchurch

Country

New ZealandPhone+66-2-391-0577 ext 141

Fax+66-2-391-0866

Emaildarryl@eubios.info

Emaild.macer@unesco.org

This chapter discusses some general features of ethics in the diverse countriesof Melanesia, Micronesia, and Polynesia, inside the region of the world called
Oceania. Ethics has a central place in the Pacific’s indigenous knowledge
systems and processes. Researchers have also played important roles in recent
decades as they attempted to articulate Pacific values into Western social
science models. Balance is critical when practicing the ethical principles ofPacific research. Any research partnerships formed with Pacific peoples shouldbe equitable and fair for both parties, engendering symmetry in the balanceof power. Only some countries have ethics committees, and informed consent
is not always obtained. There are significant social hierarchies that affect the
ethical practices in these communities, but better community engagement isrequired to overcome social inequalities.

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Palau

Micronesia

Marshall Islands
Nauru

Papua
New Guinea

Kiribati

Solomon Islands
TuvaluSamoa
VanuatuFiji
Tonga

Australia

New Zealand
Oceania3

Introduction

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The Pacific encompasses thousands of islands and communities across the Pacific
Ocean. The most populated countries are Australia, New Zealand (called Aotearoa
by the Maori indigenous population), and Papua New Guinea. Although there arealso a number of large island nations in the West Pacific such as the Philippines andJapan, these are commonly considered part of Asia, though some of the indigenous
communities of Asia share much in common with those of the Pacific. While someof the inhabitants of those communities also identify themselves as Pacific people,
this chapter’s scope will focus on Oceania. Because other chapters in the compendium review bioethics in Australia and New Zealand, this chapter will focus on theother countries of the Pacific.

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D. Macer
Eubios Ethics Institute, Christchurch, New Zealande-mail: darryl@eubios.info; d.macer@unesco.org
H.A.M.J. ten Have, B. Gordijn (eds.), Compendium and Atlas of Global Bioethics,
DOI 10.1007/978-94-007-2512-6_86, # Springer Science+Business Media Dordrecht 20131

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The term “Pacific peoples” is an umbrella term, as is “Pacific ethics,” that in noway should diminish the richness of variety of Pacific Island nations and communities who are linguistically, culturally, and geographically distinctive from eachother, while at the same time sharing some common situations and approaches tobioethics. Further scholarship is required to fully describe the diversity of
approaches to bioethics in each community, but this review includes some generaltrends and a few specific examples, from regions of Melanesia, Micronesia, andPolynesia.
There are 22 Pacific Island countries and territories with great diversity in termsof their geography, populations, cultures, economies, and politics. Based on theirethnic, linguistic, and cultural differences, these countries and territories can be
categorized under three Pacific subregions:
Melanesia
Papua New Guinea (PNG), Fiji, Solomon Islands, Vanuatu, and New Caledonia(territory of France)
Polynesia
Samoa, Tonga, Cook Islands, Tuvalu, Niue, Tokelau, American Samoa (territory of
the USA), Wallis and Futuna (territory of France), French Polynesia (territory
of France), and Pitcairn (territory of the UK)
Micronesia
Federated States of Micronesia, Kiribati, Marshall Islands, Palau, Nauru, Guam(territory of the USA), and Northern Marianas Islands (territory (Commonwealth) of the USA)The 15 independent countries cover an ocean area of nearly 5 million square
kilometers, have over 1,500 separate languages, and vary in population fromjust over 1,000 persons to over 6 million. They are all undergoing an epidemiologic transition in health terms from mainly infectious diseases to mainly
noncommunicable diseases (NCDs). All face demographic transitions with
gradually aging populations despite the presence of many young persons
because of high reproductive rates and significant emigration of young persons
to Australia, New Zealand, the USA, and other countries. Because they
are small populations, they are particularly vulnerable to outward migration,and transitions in values are rapid with introduction of global media andcommunications.
The grouping together of peoples who have richly diverse sets of languages,
customs, cultures, and homelands involves many tensions. Some of the peoples
are grouped as nations, but in some modern nations, there are hundreds ofcommunities and language groups (e.g., Vanuatu) or thousands (e.g., Papua
New Guinea). Political power has also promoted the use of the term Pacific, toquote Tongan writer Epeli Hau’ofa, “We are the ocean, we must wake up to thisancient truth and together use it to overturn all hegemonic views that aim
ultimately to confine us physically and psychologically in tiny spaces which wehave resisted and from which we recently liberated ourselves” (Hau’ofa cited byThaman, 2002, p. 8).

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Bioethics Development

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When and How Has Bioethics Started?

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Bioethics is both a word and a concept. Bioethics in the Pacific is identified closelywith a broad concept of love binding all of life together, and the terms and values used
to translate English words of bioethical principles in Pacific languages have deep
historical roots. Although there were a wide variety of concepts prior to European
colonization of the Pacific, the modern Pacific is predominantly Christian in faith, witha blend of indigenous culture and a theocentric approach to life ethics. Thus, although
the actual word “bioethics” comes to us only from a German paper of 1927 (Jahr,
1927), amplified by Potter (1970) in English, the concept comes from human heritage
thousands of years old (Macer, 1994), and there has been rejection of attempts tointroduce the term “bioethics” when it is associated with universal ethical principles.
The concept of love as a binding force resonates well with the modern Christian
approaches of Pacific culture. This includes more than humans, however, withstrong love of animals which live in the land and water and a love of nature.
In Maori the word aroha is used to denote something broader than love but
including a oneness with nature and animals. Bioethics has origins in exploring
human relationships with animals and with nature (ocean and land) and spirituality.
Love continues to be taught to children from a young age as a noble ethicalcharacter. In Tonga, ofa, which means all forms of love, and fe’ofo’ofani, caring
love as a family, are some of the basic values taught to children from a young age
which influence their behavior. These concepts are expressed in the way that PacificIslanders care for the sick, often with practical expressions that family members
will accompany the sick person to the hospital and a relative will always stay withthe person day and night in the hospital (Mafi, 1998).
Stories explaining the deeds of past generations and the symbolic nature of thelandscape can be found in songs, laws, history instruction, and social systems(Fairbairn-Dunlop, 2009). It is not possible to trace the origin of bioethics back totheir beginning, as the relationships between human beings within their society,within the biological community, and with nature and God are formed at an earlier
stage than history provides (Macer, 1998). Love is recognized as both the biological
heritage given to humankind by genes and a social heritage, as the society tries topursue harmony between individuals and communities.
Because Pacific values and beliefs are transmitted orally, many have incorrectly
assumed that bioethics were effectively nonexistent before the expansion of modern
bioethics in the 1990s (Macer, 1998). Ethics has a central place in the Pacific’s
indigenous knowledge systems and processes. “Each daily life event is seen througha lens of ethical values, mores, and codes of conduct developed over years. Indigenous
ethical systems incorporate technical insights and wisdom-based observations of
natural, social, and spiritual phenomena which, in turn, validate place and identity,
as well as the survival of Pacific nations in our increasingly globalized societies”(Fairbairn-Dunlop, 2009).

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Ethical values and principles have developed in the context of epistemologicalsystems and are central to how knowledge is gained and organized, how knowledge
is used, and who has access to it. In the development of ethical principles for
medical research, the Pacific Health Research Council in New Zealand wrote:
Every Pacific society has a framework of knowledge that is systematically gathered andformulated within a paradigm of general truths and principles. Knowledge gathering andsystems of validating knowledge and legitimizing information are processes that are often
determined and regulated (but not exclusively) by a select group within the traditional
hierarchy of knowledge with the aim of protecting the quality and wellbeing of people(Health Research Council [HRC], 2004, p. 10).

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Tui Atua Tupua Tamasese Ta’isi Efi (2009) described the importance of the
Samoan concepts of tapu (the sacred) and tofa sa’ili (the search for wisdom) in
identifying ethical practices for application in research. He argued that it is possible
to find a middle ground between ideas and practices grounded in religion, the spiritual,
the sacred, and science. Against the background of an exploration of different facets of
the Samoan concept of tapu, which encompasses the sacredness of the origins of allthings as well as the affinity between people, the cosmos, and animate and inanimate
earthly phenomena, he envisages a Pacific bioethics that reaches out for wisdom. Such
activity and the search for knowledge would be grounded in a sense of connectedness
to all things, the awareness of people’s responsibilities as protectors of the earth,attention to the sacred essence of all things, and a desire for increased understanding
without ever presuming to know God.

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Who Have Been the Major Actors/Forces?

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Colonization has been a major force to articulate bioethical value systems that werepreviously implicit in the relationships of people and nature. Along with colonization came waves of Christian missionaries, and the Christian faith was readily
adopted in a “Pacific” form. Anthropologists also described a number of traditions,although some “sacred” knowledge is preserved among chiefs and only informed tothose they decide to entrust such wisdom to. As more persons left the shores of theislands to study, they started to document more of these traditions, and in turn, thesevalues in a more articulated form were discussed among many of the communities.
There has been funded medical research throughout much of the twentiethcentury. From New Zealand, the first research was funded in 1946 (Rankin,1997). Pacific people are shifting from historically being the subjects of research
to becoming active agents of research, but still some are concerned that they areover-researched. “Although there have been positive outcomes, there have also
been instances where research has resulted in Pacific peoples being presented
inaccurately, or in a negative light. There is also a history where the benefits ofresearch have not been shared with the research subject population” (HRC, 2004).
Researchers have also played important roles in recent decades as theyattempted to articulate Pacific values into Western social science models. Theoretical frameworks include the “Metaphor of Kakala” (Helu-Thaman, Tonga),

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the “Faafaletui Model” (Tamasese, Peteru, and Waldegrave, Samoa), and the“Tivaevae” (Maua-Hodges, Cook Islands). These are frameworks that are basedon Pacific values and necessitate the use of research methods that are mostappropriate for Pacific peoples. The recognition of the need to govern research in
the Pacific in a way consistent with historical Pacific values was behind thedevelopment of the “Guidelines for Pacific Health Research in New Zealand”(HRC, 2004). Those guidelines describe 11 principles that can be found to somedegree in a number of international texts but are well accepted because of theconsultation process associated with the document. They are centered on relationships as the overarching principle that binds each of the following ethical researchprinciples: Respect, Cultural Competency, Meaningful Engagement, Reciprocity,
Utility, Rights, Balance, and Protection. These have been identified as the guiding
principles for conducting ethical relationships for research. These values area summary of many of the values found around the Pacific, and further examplesof values will be discussed when reviewing specific cases.
To develop, cultivate, and maintain principled relationships between persons
and communities is integral to all ethical practice in the Pacific, more than individual rights. Each person is a member of the whole, and the whole includes the parts.
Therefore, the bioethic is centered on building and maintaining ethical relationships. For example, the term Va Fealoaloa’i refers to the various spaces and places
within which Samoan people interact in a meaningful and non-coincidental way
and makes people sacred.
The research should enhance relationships, and an action may be deemed
unethical if it harms relationships not only between people but also with nature.
The relationship between the researcher and the research participant is based on
respect for the inherent value of each human being and on each being, whether they
be a dog or a tree. Rather than promoting a universalistic worldview, to practice ina culturally competent manner, the researcher must have an awareness of their own
cultural beliefs, values, and practices and an understanding of how these impact
upon their interaction with others. The beliefs, knowledge, and experience of theresearch participant are true to themselves, and the researcher must respect thiseven if it is different from their own beliefs, knowledge, and experience.
Researchers are encouraged to build their cultural knowledge of the Pacific communities they work with. Researchers are encouraged to create safe and enabling
research environments that support culturally competent practice, to seek ethnicspecific and context-specific advice on culturally competent practice, and to understand the importance of communicating appropriately translated information to
Pacific people.

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What Have Been the Major Concerns Over Time?

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One of the principle concerns that people have had is the lack of engagement
and miscommunication. As the HRC (2004) document states, “4.1 To conduct
ethical research with Pacific peoples there must be meaningful engagement.”

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Effective “face-to-face” consultation is critical to establishing meaningful relationships with people in most societies, and this may take longer time in many Pacificcommunities.
Because relationships between patient and health-care professional are very important, reciprocity should be a guiding principle for research relationships. This has often
been neglected in the Pacific Islands where there are significant social hierarchies.
Each individual, group, or community has the right and freedom to make an
informed choice as to whether to participate or not, in any research. However, there
have been abuses of people who have not been informed about the medical procedures. In the case of research, any risks inherent in a particular type of research must
be made clear to the research participant, and they must feel completely free as to theirdecision to participate or not (HRC, 2004). There are a number of structural societal
inequalities in most countries, so care must always be taken to protect those lesspowerful.
Reciprocity in research also requires that knowledge gained through research
will be used to benefit research participants and (where relevant) other people. If
knowledge acquired from research generates significant financial returns, then thepeople from where the original knowledge should share in the financial rewards
generated by the research. However, there have been disputes about patenting oftraditional medical compounds, and products of other wisdom, that was not compensated to the communities they came from. Any research partnerships formed
with Pacific peoples should be equitable and fair for both parties, engendering
symmetry in the balance of power.
One of the significant events was the controversies associated with intellectual
property rights (IPR) and the attempts to patent DNA in the 1990s and research to
explore human genetics associated with particular diseases. These concerns led toparticular statements such as the Mataatua Declaration (1993) as well as responses
from UNESCO (Chee et al., 1995). The Mataatua Declaration on Cultural andIntellectual Property Rights of Indigenous Peoples of June 1993 includes several
recommendations to member states of the United Nations. Recommendation 2.7
states that “commercialisation of any traditional plants and medicines of Indigenous
Peoples must be managed by the indigenous peoples who have inherited suchknowledge,” while Recommendation 2.8 demands that “a moratorium on any
further commercialisation of indigenous medicinal plants and human genetic materials must be declared until indigenous communities have developed appropriate
protection mechanisms.”
The declaration also indicates the concern for increasing capacity for research in
the Pacific, with the promotion of a “co-operative rather than competitive framework,” and an “increase in the involvement of indigenous communities” in“research and training as well as education” that would make them participants inthe process of development of industrial goods from human genome research andbeneficiaries of possible commercial profits rather than being simply suppliers ofsamples that may eventually lead to significant therapeutic discoveries.
There are differences in the views towards use of genetically modified organisms(GMOs) between the South Pacific which tends to be negative and the NorthernComp. by: Prabu Stage: Revises1 Chapter No.: 86
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Pacific which has a more positive attitude in line with the US agricultural policythat finds some genetically modified papaya and other crops being grown. Anothersignificant activity in environmental ethics was the eventual abolition of nuclear
weapons testing in the Pacific Islands, though there are still a number of islands off
limits because of residual radioactive contamination.
Overall considering the directions of cross-cultural bioethics across the globe andthe unanimous agreement with the Universal Declaration on Bioethics and Human
Rights (UDBHR, UNESCO, 2005) by nation states, there is support for the approachlinking the Pacific values of love of life with international ethical principles. However,
Pacific communities insist that there are many forms of wisdom, each found indifferent countries and communities. The Western construction of knowledge has
been questioned in a postcolonial Pacific, as many communities of persons start tothink more widely and rediscover their indigenous roots and traditions. This led tosome questioning of the Universal Declaration on Bioethics and Human Rights.
The UNESCO Ethics of Knowledge Production Conference in Dunedin in
February 2006 considered a number of issues in ethics in the Pacific includingthat document, and the outcomes formed the basis of a further conference,
Pacific Regional Ethics of Knowledge Production Workshop, held at the
Tofamamao Centre, Apia, Samoa, on 13–15 November 2007. Understanding ourselves and others and understanding place and position all contribute towards fuller
understandings of Pacific ethics, knowledge, and values. UNESCO also held
national workshops in Apia, Samoa, and Suva, Fiji, in September 2006 to explore
the concerns on so-called universal ethics. References to Christian values weremade by Pacific speakers and workshop participants, noting that the UDBHR seems
to have no spiritual grounding, as they would have liked a more Christian basis.
This may appear ironic, since the spread of Christianity in the Pacific was associated with colonization; however, it reflects the strong theocentric mentality ofunderstanding life ethics in modern Pacific culture.
Ethics systems and processes are central to every aspect of the life of Pacificindigenous communities. Although not well documented, and long disregarded in
the privileging of Western ideas about ethical practice, Pacific ethics processes
integrate epistemological, pedagogical, and methodological considerations. For
Pacific people, each daily life event is seen through a lens of ethical values,
mores, and codes of conduct that have developed over many years, while remaining
responsive to changing times (Du Plessis & Fairbairn-Dunlop, 2009).

What Resources Have Been Developed (e.g., Books, Programs,
Media, Networks, Societies)?
There are a few papers on Pacific ethics, emerging from the conferences describedabove, and networks in Asia-Pacific region include the UNESCO Asia-Pacific
School of Ethics and the Asian Bioethics Association. Some are referenced in thechapter here, but there are still relatively few compared to the diversity of values
that exist (Du Plessis & Fairbairn-Dunlop, 2009). The Asia-Pacific Science,Comp. by: Prabu Stage: Revises1 Chapter No.: 86
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D. MacerTechnology and Society Network has held several conferences on indigenous
bioethics issues, and the papers have been published (Hutchings, 2012; Yamaguchi,
Cronin, & Macer, 2012).

What Have Been the Steps/Measures Taken (Policies, Legislation,
Infrastructures, Teaching Programs, Committees, etc.)?

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The conclusion of the 2007 UNESCO Pacific Regional Ethics of Knowledge
Production Workshop was summarized in the Tofamamao Statement, which reads,
That we Pacific peoples, local and global, genealogically, spiritually and culturally connected to the lands, the skies and seas of the Pacific region:i. Undertake to lead, support and promote the development of Pacific indigenous
ethical guidelines and protocols governing contemporary Pacific research
implementation; with the respective aim of protecting, upholding and vitalising
Pacific indigenous knowledge;
ii. That such ethical guidelines and protocols take into consideration our uniqueancestral legacies governing traditional inquiry processes; and reflect a common
epistemic heritage which upholds the mana of all things, sentient and insentient,and is cognisant of tapu and sacred relations between and among all things;
iii. That we undertake these responsibilities through our institutional, cultural,religious, global, regional, national, provincial, local, governmental and nongovernmental organizations, groups, agencies/agents, families and communities; for Pacific generations, past, present and future.
iv. That the Tofamamao working Party and other interested persons and parties,
including UNESCO, should work collaboratively to advance focused activities
in this area.

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Current Bioethics Infrastructure

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Teaching of Bioethics at University and Other Levels

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There are few courses related to bioethics in universities in the Pacific, except for
the well-developed programs in Australia and New Zealand universities. Amongthese, the Otago Bioethics Centre, University of Otago Medical School, has had
significant numbers of students looking at Pacific ethics, though the focus has been
more on Maori values.

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There is a national bioethics committee in Fiji linked to Fiji School of
Medicine. Pryor, Morse, Prasad, Koloi, and Kennedy (2007) found that

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PNG, Fiji, Solomon Islands, Vanuatu, Samoa, Tonga, and Palau all havea functional structure and processes in place for the technical and ethicalreview of health research proposals. The other countries undertake an ad hocprocess as needed, although they did not find a process or structure for thisin Niue and Nauru. There is variability in the degree to which the existing
ethical review structures utilize standard operating procedures and forms tohelp guide the review process. Some of these processes for ethical review
were through National Research Committees, such as the Cook Islands. The
research committees consider ethical issues in addition to scientific aspects,
and with small populations, the case could be made for inclusion of ethicalreview duties in the total review of the application, rather than by a separate
committee.
The Vanuatu National Cultural Council is responsible for research (see Chap.
186, 6(2) of the Laws of the Republic of Vanuatu). The Vanuatu Cultural Centre is
the executing arm of the National Cultural Council and responsible for
implementing the policy. The guidelines identify priority research topics, charge
fees for applications for research, consider traditional copyright, and request
Vanuatu participation in research and training.

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Expert Bodies/Centers

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There are no bioethics centers in Oceania, except for those in Australia and New
Zealand. In Oceania, the University of the South Pacific (head office, Nandi, Fiji) is
the main research university in the Pacific, and some researchers have exploredbioethical topics. Because the academics are spread out over many small campusesin different islands, they often take the role of generalists and may also play
important roles in community decision making. Informal decision making by elders
and those considered “wise” plays a role that at times substitutes for formal ethics
committees.

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Relevant Legislation

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While Pacific research continues to emphasize the endurance of customary ways,
there is also a growing recognition of the role of universal rights and principles.
For example, the recent public monarchy confrontations in Tonga (2005) began
on a platform of poverty-related grievances, but they moved quite quickly toimpassioned appeals for rights and democratic principles. Sovereignty issues arealso gaining prominence in Pacific Small Island Developing States (SIDS) –including the emergence of more critical appraisal of the relevance of global
conventions to the Pacific and the “right” of external agencies to set those
agendas.
Case law in most countries upholds the principle of informed consent.

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D. MacerFiji in its 1997 modification to its Constitution applied a number of ethicalprinciples of the 2005 UDBHR for medical research, for example, some
excerpts:
Chapter 4, Section 22, Life: “Every person has the right to life. A person must not be
arbitrarily deprived of life.”
Section 23, Personal liberty: (1) A person must not be deprived of personal liberty except:. . . (g) for the purpose of preventing the spread of an infectious or contagious disease;(h) for the purpose of the person’s care or treatment or for the protection of the community
if he or she is, or is reasonably suspected to be, of unsound mind, addicted to drugs or
alcohol or a vagrant; or . . .
Section 25, Freedom from cruel or degrading treatment: (1) Every person has the right tofreedom from torture of any kind, whether physical, mental or emotional, and from cruel,inhumane, degrading or disproportionately severe treatment or punishment. (2) Every
person has the right to freedom from scientific or medical treatment or procedures without
his or her informed consent or, if he or she is incapable of giving informed consent, without
the informed consent of a lawful guardian.
Section 37, Privacy: (1) Every person has the right to personal privacy, including the rightto privacy of personal communications.
Section 42, Human Rights Commission: (1) This section establishes a Human Rights
Commission.
Section 38, Equality: (1) Every person has the right to equality before the law. (2) A person
must not be unfairly discriminated against, directly or indirectly, on the ground of his orher: (a) actual or supposed personal characteristics or circumstances, including race, ethnic
origin, colour, place of origin, gender, sexual orientation, birth, primary language, economic status, age or disability; or (b) opinions or beliefs, except to the extent that those
opinions or beliefs involve harm to others or the diminution of the rights or freedoms ofothers; or on any other ground prohibited by this Constitution. (3) Accordingly, neithera law nor an administrative action taken under a law may directly or indirectly impose
a disability or restriction on any person on a prohibited ground. (4) Every person has theright of access, without discrimination on a prohibited ground, to shops, hotels, lodginghouses, public restaurants, places of public entertainment, public transport services, taxis
and public places. . . .

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There have been public debates over the use of genes from living organisms
found in the Pacific for development, especially when attempts to patent thesegenes have been made (Mead & Ratuva, 2007; Ratuva, 2009). One of thefamous cases is the Hagahai patent from a PNG tribe. In March 1995, theUnited States government issued a patent on a human cell line from anindigenous Hagahai man from the rain forests of Papua New Guinea. The US
National Institutes of Health (NIH) were issued patent No. 5,397,696 by the
Patent and Trademark Office (PTO), the first time that an indigenous person’s
cells have been patented, and there was much debate until its eventual reversal(Robie, 1997).

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Other

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A substantial proportion of Pacific persons live in Australia and New Zealand(Dunsford et al., 2011). Some of the traditional ethics influence the actual bioethics
that governs the interactions of citizens and health professionals in those countries,
and readers should refer to the chapters on those countries.

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Beginning of Life

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Most Pacific countries have Christian faith. However, abortion is available withvarious criteria considering the health of the mother and fetus. Let us explore indetail a Samoan analysis of Tui Atua Tupua Tamasese Efi (2009). The Samoan term
faatosaga literally means “planting and growing the seed,” which advocatesa particular model for encouraging successful fertilization where the techniquesof fofo (massage) and a strict regimen of physical health and diet are prescribed.
According to the traditional midwives, faatosaga, the main objective of the massage is to place the fallopian tubes in the best possible position to the ovaries. This is
to help ensure the ease of passage for male sperm. The main objective of healthyeating and exercise is to ensure that the body and mind of the potential mother are insynchrony. Harmony of the mind and body allows for easier (and more enjoyable)sexual activity, which is considered a necessary precursor to successful conception.
From the moment the egg is fertilized and the mother experiences the symptomsof conception, a human life is said to exist. Here, the fetus is recognized as a person.
As a person, the fetus gains a sacred essence. It becomes tapu. When the fetus isdeliberately terminated by abortion, a breach of tapu has occurred. Pardon must besought for this breach. Throughout the process from conception to birth, the main
job of the faatosaga is to steer the mother using massage and good advice towards
a successful birth. The regimen of massage and counseling is holistic. The
relationship between the mother and the unborn child is sacred. In ancientSamoa, once conception was established, there was a ritual celebration. This was
known as afuafua (literally, meaning beginning). The prayers, chants, and rituals of
the afuafua are today replaced by Christian prayers and special food, in the few
families which still practice it.

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End of Life

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Traditional medicinal remedies are still widely used, and some of these offer painkilling properties. Although active euthanasia is rejected, there is a recognition of
the limits of Western medicine as well as limited intensive care facilities in mostislands. Rather than sending elderly relatives to distant hospitals on other islands forintensive therapy, palliative care among family may be preferred.

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Health and Disease

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Diabetes is a major health issue with Western diets, leading to significant obesity,with its associated morbidity and mortality. Tropical diseases are a significant issue
in some islands, such as Papua New Guinea. Some parts of the disease require
storage of samples in a refrigerator.

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Health-Care System: Access to Health Care

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Pryor et al. (2007) studied the health-care systems in 15 Pacific countries anddescribed wide diversity in the governance and management of the health-caresystems. Palau was an exception, having the highest per capita GDP and highest
Human Development Index, with substantive overseas health research partnerships,
associated with its close association to the USA. The Melanesian and larger
Polynesian countries generally have a more developed national health researchand health-care structure and management processes than the smaller Polynesianand Micronesian countries.
The fundamental belief is that family communal systems ensure the spiritual,
economic, and social security of family members, and they set the standards for all
behavior. This knowledge has been passed on by word of mouth, from generation to
generation (Fairbairn-Dunlop, 2009).

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Traditional Medicine

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445

Traditional practices and holistic approaches to health are common. For example,
see the Samoan example of birth, described above. Traditional medical knowledge
is extensive, and medical wisdom is one of the sacred knowledges associated withtraditional healers.

446

Genetics

447

Access to genetic testing services follows the general trends for the health-caresystems, which can be difficult on dispersed small islands. There will be significant
improvements in access as genetic testing kits become cheaper and require lesstechnical support.
There was some debate over a possible tendency for increased violent
tendencies in those children exposed to childhood abuse who were born withhigher monoamine oxidase A (MAOA) levels, in what was commonly termeda “warrior gene.” Gillett and Tamatea (2012) urged persons to focus on themain causative elements of family cycles of abuse, rather than complex genetic
possibilities.

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Reproductive Medicine

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Life is to be promoted, and having birth using assisted reproductive technologies can be supported, with the right attitudes. Extended family systems havealso allowed adoptions of children into nuclear families that do not havea child.
The use of a dead fetus for research is a breach of tapu. To tamper with the bodyof a dead fetus is to show disrespect for the sacred. The dead body returns to its
Creator after death without having been tampered with. It is to return by the very
route of its birth back to the earth. This principle of respecting the origins of humangenealogical links with the earth is implicit in ancient Samoan practices of rituallyburying the placenta and umbilical cords in the earth. Regarding the tapu on
burying the placenta and umbilical cord, the cultural claim to any land or earthly
inheritance is premised on a genealogical connection with the earth. The sacredaspects of rituals are commemorated in a belief held among most faatosaga thatomitting to bury the placenta and cord in the earth can materially affect people.
The faatosaga suggests that a dead body, born or unborn, belongs at death to noneother than God, the Creator Progenitor, and so should be returned to Him without
being tampered with. This, too, has significant implications on research using
cadavers.

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Medical Research

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Pryor et al. (2007) found in a survey that few countries had a clearly articulated
policy on health research. Among 15 countries, only 4 have invested in dedicatedpersonnel and/or a dedicated unit responsible for development in the area of healthresearch and evidence-based policy and practice (PNG, Fiji, the Solomon Islands,
and Tonga). Only PNG had specific legislation on health research pursuant toestablishing the PNG Institute of Medical Research (PNG-IMR).
Papua New Guinea (PNG) with its great diversity of population groups has
a history of exploitative anthropological research, and some controversies regarding HIV testing and vaccine trials, because of the high HIV rate. One of thechallenges for new drug development is that the population sizes are low whichmeans that there are few persons available for any one clinical trial. This has also
led to a phenomenon of persons being “over-researched,” with some resentment ofresearchers if there is no expected benefit.
The rights framework used in modern medical research guidelines is considered to
be based on individualized understandings of ethical practice and Western notions ofautonomy, individual responsibilities, and freedoms. This contrasts with Pacificnotions of interrelationship, responsibility to others, and decisions made with due
consideration of the consequences for all (whom one is connected to). The issue ofa collective – as opposed to an individualized – understanding of rights goes beyond
the issue of consent. Pacific people are advocating for the validation of alternative

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ways of viewing and approaching rights (New Zealand, 2007). For example, collectivist understandings of rights can be described in the following ways:
There are situations where the “I” (or individuals) do not have the right orauthority to give consent for something that is communally owned.
• Rights are inseparably bound to responsibility.
• Rights only occur within the context of relationships.
• A collective rights framework is based on an understanding of humanity that is
relational, collective, and concerned with others, as well as the individual.
• The concept of the individual is not negated, but instead they are viewed ascontributors to collective and communal development.
Individuals are primarily seen as agents who contribute to collective and communal development with specialist skills, knowledge, and talents. Some of thesefeatures are seen in the New Zealand Health Research Council (HRC, 2004)
Guidelines for Pacific communities discussed above.
If research targets the Pacific population, Pacific peoples should participate at alllevels of that research project. Participation of Pacific peoples in a research projectis encouraged on a number of levels, e.g., investigators, advisors, students, andinterviewers, and can provide support for Pacific members of the research team.
This concern has also been raised regarding the level of participation in discussionsof bioethics.

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Public Health

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The Secretariat of the Pacific Community (SPC) has a public health programthat supports Pacific Island communities. There is substantial funding also from
Australia, New Zealand, WHO, and the USA to supporting these programs. The
stated goals on the website are “The SPC Public Health Division (PHD) is dedicatedto improving the health, and therefore the future, of all Pacific Islanders. PHD
strives to promote and protect the health of Pacific Island peoples. It advocatesa holistic approach to health, supports sustainable capacity development, andfacilitates and promotes collaboration with partners.”
At the 2011 Pacific Islands Forum leaders meeting in Auckland, the political leadersrecognized the seriousness of the threat that noncommunicable diseases (NCDs) poseand declared the “Pacific is in an NCD Crisis.” The leaders expressed their deep
concern that NCDs have reached epidemic proportions and have become a “human,social, and economic crisis” requiring an urgent and comprehensive response. There isan SPC campaign for a healthy Pacific lifestyle, with focuses to promote physicalactivity and healthy nutrition and to combat alcoholism and smoking.

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Infectious Diseases

534

The Samoan pandemic influenza case in 1918 clouded relations with New Zealandwhen a ship with many patients was allowed to dock leading to many deaths among the

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resident population. There are laws regulating infectious disease control, and/or publichealth, in many countries. In the Constitution of Kiribati 1979, for example, it reads:
Chapter II, Section 5, Protection of right to personal liberty: (1) No person shall be deprived ofhis personal liberty save as may be authorised by law in any of the following cases, that is to say- . . . (h) for the purpose of preventing the spread of an infectious or contagious disease; (i) in thecase of a person who is, or is reasonably suspected to be, of unsound mind, addicted to drugs or
alcohol, or a vagrant for the purpose of his care or treatment or the protection of the community.

551

The Secretariat of the Pacific Community (SPC) has been engaged in issues
relating to HIV and other sexually transmitted infections (STIs) for the past 15
years. Its position has evolved according to the needs of the Pacific Island countries
and territories (PICTs) and in response to emerging trends in HIV and related issues.
The Pacific Regional Strategy on HIV and other STIs 2009–2013 as well as the PacificRegional Strategy Implementation Plan II (PRSIP) are available online (SPC, 2013)(http://www.spc.int/hiv/index.php?option¼com_contentandtask¼blogsectiona
ndid¼12andItemid¼123). In addition to HIV and STIs, there are efforts tocombat tuberculosis among other diseases.

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Transplantation Medicine and Organ Donation

553

Full range or organ transplantation services are offered in Australia and New Zealand,though patients have to wait for organs, which can be limited. However, patients inmany islands have limited services because of shortage of clinical services as well as
donors and may have to be shipped and flown to facilities in Australia, New Zealand,or Hawaii that offer transplants. In some cultures, there is a taboo against cutting up
the dead body; however, the predominantly Christian religion has been used topromote the concept of the gift of life that organ donation can provide.

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Emerging Technologies (Nanotechnology, Information Technology,etc.)
To some extent, there are two conflicting views of knowledge, that is, “sacredversus open.” One perspective is that all knowledge should be openly and freely
accessible to all. This is linked with the sense that people have a “right” to know
things – i.e., what is known and what is not known about a subject. Thus, notions ofprivacy are complex and require specific knowledge of the community, and family,
to know what should be provided.
Another perspective is that some knowledge is considered sacred, and it is notadvantageous for this knowledge to be in the public domain. To be fair, all societies
deem that some knowledge is best kept confidential or “sensitive” and is therefore
not available in the public domain. In these cases, only the “trusted” and “initiated”
have access to this knowledge, and stewards of such knowledge actively protect it.
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environment to God. The use of nanotechnology products in textile industry is being
supported, although it does not reach to many islands who will continue to use traditional
practices. There is little data processing ability to monitor what is actually happening.

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Intensive Care

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Critical care facilities exist in some islands, but ICUs are limited. There are ethicalissues of rationing and providing access to the limited number of spaces forintensive care in small Island states. Most patients will be unable to be transported
to ICUs in time, except for larger Island states.

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Palliative Care

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A time to go back to nature, and be with God, is recognized; thus, palliative care is
accepted. The care will often be given in the family setting, rather than a clinic,
event when there is an option of an ICU. The Christian faith helps a number of
persons who cannot be treated to accept death. Traditional medical therapies areused to ease the pain of some diseases and are more accessible and affordable inmost cases.

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Care for the Elderly

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There is care for the elderly in traditional community models which can haveextensive and close family networks. There has been a challenge that many
young persons have left the islands in search of employment, leaving older persons
in the care of extended family.
In some communities, there is low life expectancy, but still when persons live
longer, they will be taken care of by relatives. Emigration is challenging this whenthe elderly are left in the country, but relatives are often counted on to care for theelderly. Churches also provide broad support to the community.

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Chronic Diseases

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Chronic diseases like diabetes and cardiovascular disease are major sources ofmorbidity and mortality and targets under the public health campaigns.

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Psychiatric Care603

A holistic approach to health used in traditional practice includes counselingand emphasizes relationships among people rather than individual patients with

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mental disease. There are also laws regulating the protection of patients with mental
diseases in many countries. One of the ethical debates in these cases is whether the
disease is due to the presence of evil spirits, or ancestors, in a sense similar to some
types of belief in karma seen in Southeast Asia. In that sense, psychiatry is lessrecognized as a medical art but relates to the concerns that traditional healers use
exorcism and other forms of spiritual “healing” to attempt to treat.

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Pediatric Care

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In some countries, there are good networks of pediatric care, and in critical cases
the children may be sent to Australia or New Zealand to be with families there, incities with modern health-care facilities (Dunsford et al., 2011). One concern has
been the sensitive issue of child abuse by parents, which is a concern expressed bysome, but also has been linked to calls of racial profiling in communities of PacificIsland peoples in Australia and New Zealand. However, there is no doubt that all
peoples wish their children to be treated, but lack of knowledge of mental healthissues may see reduced empathy in some circumstances. The statistics present
a poorer record of child care in some communities, but the causative factors are
not simple.

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Emergency care ranges between advanced in a few cities and local community
measures in the islands that are very remote. For some islands, the only possibilityof air emergency services would be helicopters if they are available, and at times
cruise ships may provide emergency services for local communities. For example,
Tokelau in 2012 decided not to build an airstrip on the precious land, rather
renewing a ferry ship that requires a 2-day passage to Samoa.

629

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General practice is guided by the ethics of relationships and love. There is stilla tendency towards maternalistic or paternalistic decision making in medical
choices, although younger generations who return from more Western countries
may expect greater communication, more shared decision making, and more
informed consent. Officially the practice of informed consent is promoted in all
countries; however, in practice the benevolent physician, midwife, or nurse may be
more influential for decision making.
At the same time, there are laws specifically for health practitioners in Cook
Islands, Fiji, Kiribati, Nauru, Solomon Islands, Tonga, Tuvalu, and Vanuatu. Theselaws focus more on professional conduct and generally do not enshrine detailed
descriptions of informed consent, for example.

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Health Promotion and Education

642

There are national campaigns for healthy lifestyles through schools, tribal chiefs,
and community centers. Obesity and lack of activity are recognized as major
health problems, and community bodies such as churches can also assist inpromoting health. Obesity can be even more of a problem among Pacific persons
living in Westernized environments in Australia, New Zealand, and the USA,with access to carbonated drinks and fast food, despite the health education in
those countries.

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Scientific and Professional Integrity, Conflict of Interest, andCorruption

661

There have been attempts to regulate scientific research and control corruption in all
countries. The principle of trust is important among the relationships that people make.
In particular areas, model legislation to govern the practice of researchers has been
proposed, such as the draft Model law for the protection of traditional knowledge andexpressions of culture, 2002 (the Model Law) which is an attempt by Pacific Islandstates to protect their traditional knowledge and expressions of culture. The draft Model
Law was a result of a joint effort of Secretariat of the Pacific Community (SPC), PacificIsland Forum Secretariat, UNESCO, and the Council of Pacific Arts comprising the
27 countries and territories which participated in the Festival of Pacific Arts. It wasendorsed by the First Conference of Ministers of Culture of the Pacific Region at SPC in
2002 [online] available from http://www.mabs.jp/countries/others/pdf/331e.pdf.

662

Relations with Industry and Donors/Sponsors

663

The traditional views on knowledge in Pacific societies is that it is collective andaimed at maintaining the relationships between people – past, present, and future
generations – and the environment. While ownership of knowledge is familial andcollective, differentiation can be made between knowledge that is protected andknowledge that is shared. In addition, because the focus is on maintaining relationships, knowledge sharing is an interactive and dynamic process.
It is not surprising therefore that there have been some controversial cases whenpharmaceutical companies become involved in genetic prospecting. One caseinvolved an agreement between the King of Tonga and a biotechnology company
for human genetic sampling in the Tongan population, which, after controversial
publicity and dissent, was terminated before sampling of the population was made.
The King initially gave consent for the whole country to provide genetic samples tothe company who could explore potential commercial uses of the genetic markers
associated with diseases in some individuals in the community. It was ethicallyquestioned whether any head of state could give consent on behalf of any ethnic
group or country, and the decision was reversed after public outcry.

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The question of who owns the primary knowledge that is derived from theexperience and expertise of participants suggests that this knowledge indeed belongs
to the research participants. The question as to who owns the combined outputs of theaccumulated primary knowledge suggests that this belongs to the community ofPacific families and the community of researchers. Researchers should, where appropriate, protect indigenous Pacific knowledge and knowledge holders.

685

Future Challenges

686

In the Field of Bioethics Infrastructures (Need for Legislation, Ethics
Committees, Ethics Education, etc.)

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706

Capacity and capability building is a tangible example of reciprocity in action that is
expected of any researchers who operate in the Pacific. It will demonstrate
a commitment to the empowerment of the Pacific community. Participation is an
important principle of Pacific research. Pacific research requires the active involvement of Pacific peoples (as researchers, advisors, and stakeholders), and Pacific people
will no longer just accept to be the subjects of research. Where a research projecttargets Pacific populations, Pacific people should participate in the research team at alllevels (e.g., interviewers, research assistants, investigators, and advisors). This ensuresthat the project is responsive and accountable to the research needs of the participant
research population.
There is a core belief in many Pacific communities that knowledge should be
used responsibly, and with wisdom, so as to not harm others. Pacific knowledge istied to the collective good. To transmit knowledge to those who are not able to carefor that knowledge, process it appropriately, or keep the meanings safe can however
be seen as an irresponsible approach to knowledge. In the traditional Pacificcontext, a person earns the right to know through proving that they are worthy
and ready for the information. This prevailing attitude may mean that someresearchers face barriers that they might not experience if working witha different population.

707

In the Field of New and Emerging Issues

708

Although there have been several subregional bioethics meetings and UNESCO
also organized workshops in Samoa and Fiji, there are still many communities
in the Pacific who have not been involved in discussions of bioethics. Without
considerably more expense, it will be difficult to describe the ethical worldviews
and practices of all the diverse communities across the Pacific. Inclusiveness isimportant to Pacific values, and thus until describing more of the variety of ethicalviews scholars and policy makers have, we cannot adequately describe what is
the representative regional ethics, as we will not have adequate participation todescribe what is “Pacific bioethics.” There is a continued need for more indigenous

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research, including the mobilization of researchers and communities, healing,decolonization, and transformation (Smith, 1999).
An extension of love to other species and the concept of stewardship is one
important lesson that could be applied to environmental ethics and ethics of climatechange globally. Stewardship can apply to both the way people use other humans
and the rest of nature. The concept has often been neglected but has a long history inmany religions, being central to a Judeo-Christian doctrine of creation (Macer,1998). Usually people prefer to ignore it and to think of dominion of humans
over the earth, treating the earth with little value; however, this has caused manyenvironmental problems. There are numerous pollution problems that affecthumans and other species.

Any Other Problems and Opportunities for the Further
Development of Bioethics in the Country?

738

Few would question the need for the Pacific to develop legislation and policies
in bioethics that will guide national decision making and also protect Pacificcommunities from incidents such as external researchers carrying out researchin the Pacific that would be prohibited in their home country and acts ofbiopiracy.
There is also a great opportunity for research and scholarship to document
indigenous ideas and see how these are applied to contemporary challenges.
There is a delve of research and, with proper partnerships, tremendous potential
to rediscover many lost values and ideas.

739

Summary Conclusion

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There is diversity of circumstances among the different Pacific countries and territories and diversity of language and worldview. However, some common principles
of community involvement and participation emerge across all communities in the
Pacific (Macer, 1994, 1998). The Pacific concept of va means the space between
people – “the space that connects rather than separates” (Mila-Schaaf, 2009).
By nurturing va, relationships among people and between them and everything else
can be sustained. Pacific ethics is thus based on relationships between persons,organisms, and God, rather than rights.

748

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D. R. J. (1995). Bioethics and Human Population Genetics Research. Report of UNESCO
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