Signature: Med Sci Monit, 2003; 9(2): RA49-54
PMID: 12601306

Received: 2002.08.21
Accepted: 2003.01.07
Published: 2003.02.25

WWW.MEDSCI MONIT.COM

Review Article

Policy and ethical issues in applying medical
biotechnology in developing countries
Minakshi Bhardwaj abcdefg, Darryl RJ Macer adefg
Institute of Biological Sciences, University of Tsukuba, Tsukuba Science City 305-8572, JapanRA

Summary
A brief review of some of the key issues in policy relating to the ethical issues raised by medical
biotechnology in developing countries is presented, using India as an example. A series ofsome key issues is discussed, including information obtained from interviewing Indian government policy makers. Some of the issues discussed include: Economic and social incentives
to encourage biotechnology; Health policy and ethics review; Patents on drugs; Medical
genetics; Relationship to traditional medical practices; Positive public attitudes to biotechnology; Limited public participation; Infrastructural hurdles; Indian progress in stem cellresearch; and dilemmas of expensive technologies. The results show that although the needsof developing countries are different to those of rich countries, government policy utilizing
guidelines and ethics committees has evolved as mechanisms to aid ethical health care delivery
in India. In all countries there may be some of these concerns that are raised here, however,
the integration of traditional medicine and advanced medical technology, and access to medical services by people in need, are particularly important challenges in developing countries.
Better public involvement in policy making will require education and infrastructural organization as well as mutual willingness on the part of policy makers and citizens.

key words:

India • policy • bioethics • biotechnology • developing country

Full-text PDF:

http://www.MedSciMonit.com/pub/vol_9/no_2/3030.pdf

Word count:
Tables:Figures:
References:

4167
—
—
24

Author’s address:

Minakshi Bhardwaj, Institute of Biological Sciences, University of Tsukuba, Tsukuba Science City 305-8572,
Japan, email: bminakshi@hotmail.com, macer@sakura.cc.tsukuba.ac.jp

RA49

Review Article

1. BACKGROUND TO BIOETHICS AND MEDICALBIOTECHNOLOGY

Human beings have been using nature and its products throughout history. We can define biotechnology
as the use of living organisms or parts of them to provide goods or services. Medical biotechnology isapplied to the diagnosis or treatment of a disease. Useof technology in living organisms has been subject todebate, and has often posed questions of medical
ethics and policy.
In the 1970s the field of medical ethics evolved into a
more philosophical analysis called bioethics [1].
Bioethics emerged as an independent field when developments in medical and biological sciences started challenging the ethical implications of scientific progressand established principles of medical ethics were unable
to satisfactorily answer them. Bioethics encompasses
both medical ethics and environmental ethics, including
areas like public health. It is a multidisciplinary subject
including medicine, environmental sciences, humanities
and philosophy. Balancing of ethical principles can aid
rational decision making; and the four fundamental
principles of bioethics include autonomy (self rule), justice (love of others), non-maleficence (do no harm or
loving life), beneficence (loving good) [2,3].
Although the principles of bioethics and moral theories
are universal at one level of comparison because of thecommon biological and social heritage of every culture,
there are subtle cultural differences. Ethics in Asia
focuses more on human attitudes to nature and relationships with other members of the biological community rather than a modern North American conceptthat the basic social unit is a human person as anautonomous unit [4]. Societies vary in their emphasis
on individuals or families as units that interact withhealth professionals. Societies are also under transition
from paternalistic systems of relationships between
health professionals and patients to choice-based societies.

2. METHODOLOGY OF INTERVIEWS IN INDIA
India is usually referred to as a ‘developed developing
country’, so it faces problems of both developed anddeveloping countries. India is country of more than one
billion people and the main reason for promoting
biotechnology and medical research is not only to
reduce the burden of disease in the nation but also to beequally compatible with the world in scientific research.
In order to provide some perspectives on how policy is
being debated in India interviews were conducted withgovernment officials on various biotechnology issues indifferent ministries and government institutions. This
paper includes some example comments that were
given during interviews in November 2001. The interviews focused on the bioethical challenges these 24 policy makers faced in developing policies in biotechnology
and genetics research in India. Only 4 of the subjects
were female, and 15 of the 24 subjects agreed to being
tape recorded. Interestingly most of those who did not

RA50

Med Sci Monit, 2003; 9(2): RA49-54

wish to be recorded were in more junior positions, as
they were more fearful of being quoted, although we
guaranteed their anonymity. Some of the interviewees
were members or having observer status in the different
ethics committees or review boards set up by the government or its institutions.
The institutes that were surveyed included the All India
Institute of Medical Sciences (AIIMS), which is thebiggest government hospital in India; the Departmentof Biotechnology (DBT) under the Ministry of Scienceand Technology which serves as a nodal point for all
biotechnology related research; Indian Council ofMedical Research (ICMR), the apex body in India for
the formulation, coordination and promotion of biomedical research; the Ministry of Health and Family
Welfare; and National Institute of Science Technology
Advanced Development, an Institute responsible fortransfer of technology, linking people to technology andpromoting federal efforts at local level.

3. ECONOMIC BARRIERS TO MEDICINEAs the world’s largest democracy with more than half
the population below middle class, there are many
infrastructural problems that face developing countries,
such as bureaucratic structures, corruption, lack of universal health care access. Above all the lack of funds for
medical care experienced by so many people is dominant for a developing country and limits the choices
open to its citizens [5].
Many administrative hurdles make it difficult to keep
pace with international research, as was observed by one
doctor, stating, ‘ Personally I feel that finance is not a major
constraint. DBT has put lot of money in it, the main problem isthe bureaucratic hassles. First is the approval and then it takes
months to release the funds’. There is a three tier healthsystem, the rich, the middle class, and those who cannot
afford to pay who must rely on the generosity of hospitals and donors. Discrepancies over private and public
hospitals were raised as one interviewee said,‘Government hospitals are cheaper but less equipped with goodfacilities, and private clinics apply good services to patients’.
People have to pay, as a public medical practitioner said,‘Government sector gets chocked because of the rush of patients,
even then anyway 90% of the money patients still have to pay,theoretically it may be free but still you are asked to buy smallthings’.
There is much enthusiasm among scientists and government in India about the prospects of genome researchand stem cell research in India. There is a specific government Department of Biotechnology, reflecting thepositive attitude of the government. There is some senseof national pride to try to use the resources available
within the country considering the great diversity ofgenetic resources that could be ‘tapped’ for genetics
research because of the diverse ethnic groups (over 300
official ethnic groups) and the multi-cultural social system in the country. The motivation is also economic
development, something that has not been a priority formany smaller developing countries.

Med Sci Monit, 2003; 9(2): RA49-54

There are a number of critics of this emphasis however,
and many criticize that any venture into genomics will
not be considered as a first priority for India. As one
person said, ‘strategically genomics does not fit into our priorities, it has a long gestation period, we can’t expect results in anyear or two, so it would not be good to divert resources fromensuring primary and secondary health care to genomics’. Thisis a practical dilemma facing health care professionals intheir choice of vocation also, i.e. whether to devote theirtime to the immediate needs around them or to contribute to a long term research project with uncertain
rewards for society. Nevertheless, there needs to behealth research in order for developing countries toovercome the burden of disease and accidents thatafflict them [6]. Because the needs of a developing
country are particular, a local system of health researchis necessary for development of capacity, knowledge,
utilization and management of knowledge and for themobilization of resources [7]. These research systems
often do not include sufficient resources for examining
the social and ethical dimensions of health, although
this type of research is within the financial means ofmost developing countries.
Global inequity is not a new problem but it is of central
importance. Because of the importance of international
protection of intellectual property rights (IPRs) for technological and cultural exchanges and promotion of free
trade there is an international system for IPRs. IPRs
regarding biotechnology have been discussed at various
international forums including WIPO, WTO, UNESCO[8], and UPOV, as well as at each national patent office.
By April 1998, 132 countries had signed the Trade
Related Aspects of Intellectual Property Rights (TRIPs)
agreement, discussed under the General Agreement on
Tariffs and Trade (GATT) and the WTO. There havebeen possible conflicts observed in article 27 of theTRIPs agreement by the United Nations Commission
on Human Rights [9]. The right of governments toimpose compulsory licensing in medical interventions toprotect public health was affirmed by WTO in the Doha
Declaration [10]. India has been involved in several
international disputes related to U. S. companies claiming patents on agricultural and medical products
extracted from plants long known to be medicinal, suchas the Neem tree. This issue has been raised in agriculture, considering rewards for farmers for their innovations in the development of plant and animal varieties.
There may be knowledge that should be global commons, but it is a complex issue [11].
On the issue of generic drugs and multi-national companies involvement, one person observed, ‘there is lot ofnoise about patents now because we are signatory to GATT andpatents are going to effect local pharmaceutical industry a lot.
We produce drugs at low cost which is affordable to people andalso a source of foreign income, which will vanish after 2005’.
Another person said, ‘ Local pharmaceuticals are trying to havecollaborations with MNCs because they think anyway 80% of
the core drugs are out of treatment, then better drugs throughrecombination technology will come through and would be costlier if imported. So they are gearing up for joint venture with
MNCs’. The government has a difficult job to makeBhardwaj M et al – Policy and ethical issues in applying medical biotechnology…

compromises between various voices in Indian industry
and the tradition of many NGOs in India to be leadersof global campaigns against patenting. India and China
are huge countries that have a local drug industry, andare not only recipients but is also donors of drugs. Most
developing countries are dependent upon drug donations, and there are WHO guidelines on these [12].

4. ETHICAL REVIEW OF MEDICAL RESEARCH
AND PUBLIC PARTICIPATION

Governments continue to devote increasing proportionsof their gross national product to medical care, whether
rich or poor. Concerns were raised by respondents
interviewed primarily in the provision of infrastructure
facilities, equity, poverty and other socio-economic concerns. One interviewee said, ‘There are people who canafford medical facilities with all kinds of luxuries at their door
steps and there are people who can’t afford safe food or safe
drinking water. So this kind of heterogeneity which is very
enormous is a big ethical challenge’.
In order to meet with these challenges appropriate
applications of modern biotechnology need to be continually developed. However, for the majority of peoples in the world, who live in developing countries, theimplementation of established therapies would alleviate
much human suffering, both for infectious and noninfectious diseases. This means that critics inside many
developing countries would prefer to put more funding
into implementation of therapies and disease control
rather than investment into new technology.
In India, an IEC (Institutional Ethics Committee),which is equivalent to what is called an Institutional
Review Board (IRB) in many countries, approves all the
projects involving human subjects. If the IEC has somequestions, the proposal is forwarded to the Drug
Controller General of India (DCGI) for clearance.
DCGI is considered equivalent to the US FDA. In thecase of controversies or if the trials are of national
importance they are referred to the national ethics committee under ICMR, which is decided by the Drug
Controller General of India. The national bioethics
committee looks at all the issues related with humanresearch clinical trials.
However, issues related to basic research regarding
gene therapy come under the authority of DBT. In thecase of gene therapy, somatic gene therapy is permitted
in India, but germ-line gene therapy or gene therapy
for enhancement is not allowed. A gene therapy trial
consists of two parts. The first part is preparation of thegene construct to be administered, and the second partis evaluation of the efficacy and safety of the administered gene (construct). As far as the first part is concerned, the guidelines and clearance for it is to be regulated by the National Bioethics Committee under DBT
and for the second part clearance from the local IEC
and Central Ethical Committee (CEC) of the ICMR shallbe obtained. Children could be candidates for therapy if
it is meant for a childhood disorder. For comparison,
issues related to stem cell research are first cleared by

RA51

RA

Review Article

institutional ethics committee and then referred to thenational bioethics committee for final approval.
The ICMR has taken the lead in developing ethicalguidelines for selected areas of medical biotechnology,
including reproductive technologies and medical genetics, and these are on-line [13]. There is no concrete legislative framework at the federal level on some very sensitive issues like genetic privacy, although there are
guidelines provided by the Medical Council of India(MCI) for practitioners and surgeons. There are a number of ethical issues for research in general in developing countries [14].
A common difficulty in making policy was cited as lackof knowledge and public enthusiasm for policy recommendations. Public participation is at a very low level ingovernment matters; although many people will express
an opinion when they are personally asked. One reason
for the absence of much public uproar against stem cellresearch or any other genetic technology is that the scientific research is usually conducted quietly; away fromordinary lives. Around 70% of the Indian population
lives in villages and there is wide gap in between thelifestyles of people living in villages with those dwellingin the cities. This is also a major obstacle in the flow of
information among people. Comments on pro oragainst technology are left for the NGOs and media;
rather than ordinary people.
People living ordinary lives are unaware of such developments. Lack of interest among people stems out ofvery fundamental ethical question of education. Lack of
education results in lack of interest and consequently
lack of public participation. This is a serious ethical issue
when human lives are involved. Active public participation is necessary for interactive bioethics. An example
was given by a person saying, ‘We made draft ethical guidelines in 1998 and send to more than 1000 medical professionals for comments, but only 120 replied. Following that we hadregional debates, we advertisements in the local newspapers sothat public can come and attend, hardly 2 or 3 persons came.
Public participation is limited to journalists who write on such
issues’.
Even NGOs, who bridge the gap between people andpower are thought to be too radical of any government’s
decision, because of their protests. Sometimes theirviews are alienated rather than a combined mutuality.
One person dealing with NGOs said, ‘NGOs put a lot ofpressure on government to review its decisions. But which pressure would work more is likely to be determined by all. If they
are right for one thing, they may be wrong on many otherthings’. There were concerns raised on the lack of institutional ethics committees and also lack of central
accreditation system for medical research and agriculture research, although major efforts are being taken
for decentralization of responsibilities. Decentralization
with proper controlling or regulatory mechanism wasconsidered an urgent concern in policy making.
International collaboration and private sector collaboration is considered very important for development inbiotechnology as they have the knowledge and resour-

RA52

Med Sci Monit, 2003; 9(2): RA49-54

ces for advance research. Although government haspromoted private sector collaboration, fears were raisedover a total takeover by the private sector in the processof globalization that could make things more difficult
for the general public.
Another important factor which contributes to difficulties in policy making is Indian cultural diversity makes it
easier as well as sometimes very difficult to resolve
issues. One person said, ‘it would be extremely difficult tocome out with something that can satisfy everybody. There is anupper crust that is ambitious but there is lot more below. Then
there are cultural differences from one region to another. We
can only inform people let them decide what they want. We
would have to bring something that can satisfy most if not all’.

5. CHALLENGES OF TRADITIONAL MEDICINEAND NEW TECHNOLOGY

Traditional medicines are generally exempt from review
for new drugs. The philosophy of traditional medicine
is based on the thought that nature is the mother for all
kinds of treatments and provides therapies for all diseases and illnesses. This approach has been universallyfound in all cultures of the world, although the extent
to which traditional medicine is used varies widely
between cultures. According to WHO, traditional medicine is ‘the sum total of the knowledge, skills, and practices based on the theories, beliefs, and experiencesindigenous to different cultures, whether explicable ornot, used in the maintenance of health as well as in theprevention, diagnosis, improvement or treatment ofphysical and mental illness [15]. In some African countries up to 80%, and in India 65%, of the population
depends on traditional medicine to help meet theirhealth care needs. In developed countries, the percentage of the population that has used complementary andalternative medicine at least once is 48% in Australia,
40% in Belgium, 70% in Canada, 75% in France and
42% in USA. Traditional medical practitioners, like
Ayurvedic doctors, require six years of study, which issimilar to Western medical practitioners, and can beequally professional.
Flexibility is essential as new diseases are emerging
everyday which may not be able to be combated withtraditional medicine, for example AIDS. In some cultures, for example in many African countries, there may
not only be a lack of funding for drugs to combat AIDS
but also beliefs in traditional therapies. Some of theextreme social practices in South Africa include men
raping young children because of a belief that sleepingwith a virgin will cure them of AIDS. In India persons
with HIV have been killed by some communities, despite the high prevalence of HIV [16].
The rejection of modern technology due to of culturalbeliefs and practices is not a novel phenomenon for
medicine, or other aspects of life. An example can beseen in the 19th century in India when people rejected
Western treatment for cholera and other epidemic diseases because of lack of a religious basis to the therapies.
Whether it is Islamic medicine, Unani medicine,Med Sci Monit, 2003; 9(2): RA49-54

Bhardwaj M et al – Policy and ethical issues in applying medical biotechnology…

Chinese medicine or Indian medicine the approach has
been largely experience based.

would argue sex selective abortions are one step better
than female infanticide, but it is a controversial issue.

Perhaps even more important for the ethical issues ofpractice of medicine in developing countries is the lackof informed consent in many countries. In India thecourts have recognized the concept of informed consent
and it would be an accepted norm, however exercise ofconsent and choice is limited by the situation of poverty
as in all developing countries. The cultural practices
may also make it difficult to have effective first person
informed consent [17], but at least familial level
informed consent should be practiced. The time constraints on medical consultations are a problem even inrich countries, so the practice of counseling is important. Perhaps this human interaction found with sometraditional medical healers is the reason they are so
popular still. Still access to modern medicines is important for people’s health, as found in a recent Indian
clinical trial for mental disorders, which found affordable antidepressants were more effective than psychiatric care [18].

Although many people use traditional medicine, when
asked in surveys about the use of applications of modern biotechnology, people in developing countries,
including India, are among the most positive countries
in the world [23]. This enthusiasm is even more marked
when asked about the use of genetic enhancement technologies like making children more intelligent or physically stronger [24]. Unlike respondents to surveys inAustralasia, Europe or Japan, more than half the
respondents in China, India or Thailand approve of
these hypothetical examples. The acceptance of biotechnology may be because they perceive science and technology will alleviate the burden of disease. Thus
although traditional medicine is popular, it may besometimes the chosen therapy because of its cost, availability, and the absence of anything more effective. Also
the government and media promotion of science andbiotechnology may have influenced people’s opinions to
be favourable.

Abortion and infanticide are medical practices that havetraditional roots, given that plant extracts are common
sources of the drugs that are still used in parts of India.
Modern technology has been combined with these toallow selective termination of pregnancy. In a 1993 survey 41% of Indian people strongly disagreed to abort a
4 months old fetus if it was not suffering from any diseases; the highest among the ten countries in Asia andOceania that were surveyed [19]. This shows the sanctityof life is a major ethical issue for Indian people.
Nevertheless, 38% agreed to abort if the fetus was suffering from some congenital malformations, showing
some pragmatism. This and other surveys have showedthat there were not major religious differences in
Hindus, Christians and Muslims in India when it comesto decisions over prenatal diagnosis. In Verma’s survey(N=1404), 50% of the respondents agreed that thehandicapped fetus does not have a right to life [20]. If
there was a high risk of recurrence of the handicap, one
third of the parents in such a circumstance said theywould prefer to adopt a child.

Especially after US federal funding in stem cell research
for the two leading research organisations in India,
namely National Centre for Biological Sciences (NCBS)
in Bangalore, and a recently created private researchlaboratory called Reliance Life Sciences (RLS) in
Mumbai which is ranked 3rd among the top 10 laboratories for stem cell research in the world by NIH. They
possess 2 and 7 stem cell lines, respectively. They areboth attempting to make more.

Regarding the reasons behind the support for prenatal
genetic screening, let us consider why the opinionchanged so much for a fetus with abnormality. Despite
rejection of abortion in general (15% for, 71% against),
there was conversely high support for selective abortionof fetuses with congenital abnormalities (67% for, 19%against). There was support for prenatal genetic screening under government funding (80% yes, 8% no) andfor personal use (71% yes, 17% no) [21]. Half of the persons who gave a reason made a comment suggesting
economic benefits of such screening and that healthcare was a right or that the government should pay forthe poor. There was also relatively high reasoning basedon improvement of genes (15% of those who answered).
In India there are well documented abuses of amniocentesis for sex selection [22]. A few respondents madecomments that it should not be used for sex selection,but otherwise the issue was not addressed here. Some

Concerns were raised on the use of foetal tissue for stem
cell research. Because abortion is legal, as is private
reproductive clinics offering IVF, there are a large
number of fertility clinics across India. As the Deputy
Director General of ICMR puts it, ‘the fear is that since wehave lot of spare embryos because of bloom of IVF clinics, thereis going to be great clamor of exporting embryos to get money.
Even if you try to stop it, it is not going to stop. So the government has decided to allow to continue stem cell research butwith certain conditions’. The pragmatic attitude of Indiansociety to allow abortion, ES cell research and prenatal
diagnosis, despite of the sanctity of human life (as discussed for medical genetics above) may be a reflection
on how Indian society has survived in some form forthousands of years, adapting traditional ideals to allow
the use of new technologies.
India does perform many organ transplantations, thoughconcerns over paid kidney transplant markets are high.
However only a few percent of the patients who needkidneys live. Heart transplants occur rarely. Intensive
care is a more common technology, which presents
problems as another person said. ‘’ hospitals hardly have
any heart-lung machines or artificial respirators. How can an
earlier patient be taken off when a patient comes?’.

6. CONCLUSIONS
Around 80% of the world population lives in developing
countries where people don’t even have access to basic

RA53

RA

Review Article

medical facilities and health care[6]. Health care policy
needs to be considered in the proper environmental,
cultural, social and economic context. As we can see
from the results of the interviews the particular healthstructures and socio-economic conditions of developing
countries may not only lessen the emphasize placed on
developing research in biotechnology, but at the sametime desperate situations may make people grasp at any
new tool that is perceived to be a panacea to relieve theburden of disease.
Although there is a general positive attitude for biotechnology research, the discrepancies and difficulties to get
public support and involvement are serious issues to beaddressed. Although it can be argued that the basic
moral principles can be redefined by public debates orvoting, the culture is important in how society makes adecision on the use of new technology. In this environment the open availability of ethical guidelines throughthe Internet and in printed copy provides an essential
guide for health care professionals. In this way thedevelopment of guidelines that are appropriate for theparticular country are essential for the proper utilization of medical biotechnology. Still we are concernedthat the access to commercial services such as amniocentesis for sex selection, reproductive technology, and to
drugs and hormones made by modern biotechnology
like human growth hormone, in a developing country
means it is very difficult to limit the use and misuse of
these technologies by some members of the community.
Acknowledgments
We acknowledge the cooperation of the persons interviewed in India, and especially Dr. Vasantha Muthuswamy for providing additional information on ICMR.

REFERENCES:
1. Jonsen AR: A Short History of Medical Ethics. Seattle, University ofWashington Press, 1998
2. Beauchamp TL, Childress JF: Principles of Biomedical Ethics.
Fourth Edition. New York, Oxford University Press, 1994
3. Macer DRJ: Bioethics is Love of Life: An Alternative Textbook.
Christchurch, NZ: Eubios Ethics Institute, 1998. Available from:http://www.biol.tsukuba.ac.jp/~macer/bll.html
4. Azariah J, Azariah H, Macer DRJ, editors: Bioethics in India.
Christchurch, NZ: Eubios Ethics Institute, 1998. Available from:http://www.biol.tsukuba.ac.jp/~macer/India.html
5. Azevedo ES, Cerqueira EMM: Decisions in Circumstances of
Poverty. Eubios Journal of Asian and International Bioethics, 2002;
12: 105-107

RA54

Med Sci Monit, 2003; 9(2): RA49-54
6. Global Forum for Health Research: The 10/90 Report on HealthResearch 2001-2002. Geneva, Global Forum for Health Research,2002
7. WHO Regional Office for South-East Asia: Strategies for HealthResearch Systems Development in South-East Asia Region. New
Delhi, WHO Regional Office for South-East Asia, 2001
8. Working Group of the UNESCO International Bioethics
Committee: Draft Report on the Follow-up of the International
Symposium on ‘Ethics, Intellectual Property and Genomics, Paris,
UNESCO; 29 August 2001. Available from:http://www.unesco.org/ibc/en/reports/DraftRep_IntSymp_EthPropInt-Gen_E.pdf
9. Commission on Human Rights,Resolution 200/7 (17 August 2000)
10. Doha Declaration: Declaration on the TRIPs Agreement and publichealth, adopted at the Fourth WTO Ministerial Conference at
Doha, Qatar, 2001
11. Powledge F: Patenting, privacy, and the global commons.
BioScience, 2001; 51: 273-7
12. WHO: Guidelines for Drug Donations. Revised 1999. Geneva,
World Health Organization, 1999
13. ICMR: Ethical Guidelines for Biomedical Research on Human
Subjects. New Delhi: Indian Council Of Medical Research; 2000.
Available from: http://www.icmr.nic.in/publication.html#GUIDELINES
14. Nuffield Council on Bioethics: The Ethics of Clinical Research in
Developing Countries. London, Nuffield Council on Bioethics,
1999
15. WHO: Traditional Medicine Fact Sheet. Available from:http://www.who.int/inf-fs/en/fact134.html
16. Kavitha NS, Azariah JA: Age dependent variation in bioethicalissues with reference to AIDS & its cure. Eubios Journal of Asianand International Bioethics, 2000; 10: 188-9
17. Castillo FA: Limiting factors impacting on voluntary first person
informed consent in the Philippines. Developing World Bioethics,
2002; 2: 21-27
18. Patel V et al: Efficacy and cost-effectiveness of drug and psychological treatments for common mental disorders in general health carein Goa, India: A randomised, controlled trial. Lancet, 2003; 361:
33-9
19. Macer DRJ: Bioethics for the People by the People. Christchurch
NZ: Eubios Ethics Institute, 1994. Available from:http://www.biol.tsukuba.ac.jp/~macer/bfp.html
20. Verma IC, Fujiki N, Ahuja YR et al: How rational are Indians intheir views on handicaps and heredity. In N. Fujiki N, Macer DRJ,
editors. Intractable Neurological Disorders, Human Genome
Research and Society. Christchurch, NZ: Eubios Ethics Institute,
1994; 184-187
21. Azariah J, Azariah H, Macer D: Bioethical reasoning in India. In
Macer DRJ. Bioethics for the People by the People. Christchurch,
NZ: Eubios Ethics Institute, 1994; 157-160
22. Kusum: ‘The use of prenatal diagnostic techniques for sex selection: The Indian scene’, Bioethics, 7: 149-165
23. Azariah J, Azariah H, Macer D: Bioethical reasoning in India. In
Macer DRJ. Bioethics for the People by the People. Christchurch,
NZ: Eubios Ethics Institute, 1994; 157-160
24. Macer DRJ, Akiyama S, Alora AT et al: ‘International perceptions
and approval of gene therapy’, Human Gene Therapy, 1995; 6:
791-803