Eubios Journal of Asian andInternational Bioethics
EJAIB Vol 16 (1) January 2006 ISSN 1173-2571
Copyright ©2006 Eubios Ethics Institute (All rights reserved, for commercial reproductions).
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c/o Darryl Macer, RUSHSAP, UNESCO Bangkok, 920 Sukhumvit Rd, Prakanong, Bangkok 10110, THAILAND

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Official Journal of the Asian Bioethics Association (ABA)

Contents

Editorial: Science and Culture
page

Editorial: Science and Culture1
Declaration Of Gijón Against The Use Of
Biological Weapons
2
Scams in Science3- K. K. VermaMulticultural medicine: ethical issues encountered whenperspectives differ
4- Karolyn White, Catherine McGrath, Ian Kerridge
A Book on Medical Ethics in Medieval Islam: Al-Tashwîk AlTibbî (Encouraging Medicine) of Abu’l-Alâ Sâid B. Al-Hasan
Al-Tabîb (1009-1087 A.C)
6
- Ahmet Güner
Confucian Ethics: Responsibilities, Rights, & Relationships 9- David Cummiskey
Black identity and registries in Brazil: a question of rights
and justice22- Eliane S. Azevêdo, José Tavares-Neto
Population genetics and the power of discrimination
25- Luzitano Brandão Ferreira
ABA Membership, Conferences
27
Ordering Information
28
Send papers to the editor in electronic form if possible.
Please use reference style used in News section, do not use
automatic footnotes or endnotes. Papers are peer reviewed.
Editorial address: Prof. Darryl Macer
RUSHSAP, UNESCO Bangkok,
920 Sukhumvit Rd, Prakanong,
Bangkok 10110, THAILAND
Fax: Int+66-2-664-3772
Email: d.macer@unescobkk.org

Deadline for the March 2006 issue is
28 February, 2006.

- Darryl Macer, Ph.D.
One of the biggest stories of 2005 was an unfortunatecase of scientific fraud connected to the publication ofarticles in the journal Science by the Korean stem cellscientist, professor Hwang. Scientific honesty is an
ethical principle across all cultures, and the falsificationof data in this case has led to the wastage of a large
amount of scientific resources and financial resources,and human energy. There was already a serious ethicalcontroversy over the donation of human eggs, and it
now appears even more eggs were used that disclosed inthat paper. Scams in science are not new, and willcontinue as Verma discusses in this issue, but we needto educate scientists to work honestly. As we learn moreof the affair we will probably learn of more than just one
involved in improper behaviour for not only scientists
but any professional, and any citizen.
The Declaration of Gijón against biological weapons
included in this issue is another reminder of the need forgood standards of conduct in science.
The ancient history of medical ethics is exploredwith a book review of a work from the 11th century,
which still points to basic responsibilities of physicians
today. There is an extensive discussion of Confucian
ethics by Cummiskey which explores some of thecommonly discussed issues in Asian bioethics, such aswhether there is a conflict between human rights andtraditional Chinese values. We welcome papers todebate these issues, which have been a theme at many
Asian Bioethics Conferences and other fora in the past.
There are two papers on issues of genetics, race,
identity and discrimination from Brazil. These issues
face many cultures, and especially in large urban areasthat many persons live in today.
If you wish to continue receiving a hard copy of
EJAIB please copy the last page and send back to me, or
else email the important details. Happy New Year!

2

Eubios Journal of Asian and International Bioethics 16 (January 2006)

Declaration Of Gijón
Against The Use Of Biological
Weapons
Adopted by assent of the Plenary Assemblyof the IV World Conference on Bioethics
Gijón (SPAIN), 25th November 2005
The Plenary of the IV World Conference on
Bioethics organised by the International Society of
Bioethics (SIBI) which took place in Gijón (Spain)from the 21st to the 25th November 2005,
OBSERVING− That human dignity is an attribute uniqueto all human beings and its recognition is afundamental right and the foundation of all humanrights and fundamental freedoms of each and every
individual and of humanity as a whole which must
be respected and protected,− That violence of any kind - be it physical,
psychological, emotional, moral, technical,
environmental, social, economic or any other, isunacceptable behaviour which is anti-social andcontrary to human dignity,− That war, terrorism, violence and theabuse of power, and the misuse of science andtechnology are detrimental to Humankind and thatsuch acts are increasing in number and intensity
and are often carried out without any punishment,− That the use of biological and chemical
weapons is particularly cruel and affects
indiscriminately civil populations and is forbidden
in many international and regional documents suchas:•
The Geneva Protocol dated 17th June 1925,•
The Convention on the banning on
development, production and storage ofbacteriological (biological) weapons and toxins andabout their destruction, which was opened forsignature in 1972 and which entered into force in
1975, Annex to the resolution of the General
Assembly of United Nations No. 2826 (XXVI),•The Universal Declaration on the Human
Genome and Human Rights of 11 November 1997,•
The Declaration "Universal Commitment to
the Dignity of the Human Being" II World
Conference on Bioethics, Gijón, Spain, 2002,•
The Universal Declaration on Bioethics andHuman Rights, 2005;

RECALLING the appeal of the International
Committee of the Red Cross on Biotechnology,
Weapons and Humanity;
AFFIRMING that individual and collective
human dignity is denied− If we remain indifferent to aggression by
the strongest against the weakest countries.
− If we continue to resort to the use of force,
including terror, to resolve our differences, insteadof building bridges of tolerance, understanding andconstructive communication.
CONVINCED that
− Every person has a moral obligation topromote Human Dignity and assume the defence ofthe dignity of the person and also the obligation toguard against and denounce any infringements of it.
− That Bioethics recognizes a specificobligation to denounce violations of human dignity
and to promote the banning of the use of biologicalknowledge, techniques and means to destroy andannihilate human beings and their natural
surroundings.
WE EXPRESS our firm commitment withregard to− Progressing with determination towards a
new world order that is based on justice, universal
participation, mutual responsibility, co-operation,
equity and solidarity so as to put an end to armed
conflicts, wars and terrorism,− Adopting and encouraging individual,social and political measures and attitudes in orderto defeat intolerance and violence in all their forms
and to impose the effective respect of humandignity,− Advocating destruction of all existing
biological weapon, and rejecting military strategies
which summon biomedical professionals tocooperate in the procurement, use andencouragement of biological arsenals, as well as to
publicly
condemnnon-compliancewithinternational agreements,− Requesting participation of bioethics
advocates in the commissions that have a say in thedrafting and control over such agreements,− Condemning participation of experts,
technicians and scientists in the development of
biological weapons,− Condemning participation of public healthinstitutions in schemes that aim to develop
programmes that may lead to the procurement ofEubios Journal of Asian and International Bioethics 16 (January 2006)
biological weapons which, under the excuse of their
being defensive strategies, might be applied inreprisal against others.
− Constructing coherent theoretical grounds
against the arguments that provide support toreligious wars, torture, and pro-war ethics.
− Demanding from all Governments thatthey promptly implement the measures and actions
that are required to make the present Declaration
effective.
− Widely publicising this Commitment
through all the media of communication anddemanding that it be urgently put into practice.

Scams in Science- K. K. Verma, Ph.D.
Retd. Professor of Zoology,
HIG1/327, Housing Board Colony, Borsi,
DURG - 491001, India.
Email: kkvermain@sancharnet.in
web site: www.kkverma.com
The great hoax of the Piltdown Man is still
lingering in our memory. The hoax was a creationof Charles Dawson, who claimed to have foundremains of a very primitive human in a gravel pit
near Piltdown in Sussex, England through diggingsin 1912 to 1914. The remains included some piecesof crania, a part of lower jaw with teeth and some
flint and bone implements, supposed to be those of
the primitive man. It was estimated that the remains
were about 500,000 year old. The fossils werehanded over to the British Museum. Associating thelower jaw with the reconstructed upper part of theskull, the entire skull of the primitive man was
visualized. While the upper part of the skull wasquite human, the lower jaw was ape like. The
supposedly primitive man was named as
Eoanthropus dawsoni, and was hailed as a greatfind, as it was taken as the “missing link” between
apes and man. But subsequently through x-raying
and radioactive dating the cranial parts were foundto be only 50,000 year old, and the lower jaw
fragment even younger. Similarly it was found thatthe bone implement, included in the find, had been
stained with a chromium compound to make it lookmineralized. Hence it was inferred that, while thecranium belonged to an ancient man, the jaw was ofan ape, and that the two had been wrongly
associated. Through efforts of Oakley, Weiner andother scientists the fraud was finally established.

3

On 21st November 1953 in the Bulletin of the
British Museum it was declared that the Piltdown
Man was a hoax.
Scams in science have been sporadically, thoughrarely, appearing. A recent instance is about a stem
cell research. A South Korean scientist, Hwang
Woo-suk, of the Seoul National University,
published the results of his researches on cloned
human stem cells in the prestigious journal Sciencein May, 2004. The paper was coauthored by Gerald
Schatten of the University of Pittsburg Medical
Centre; in fact Schatten was the senior author inthis publication. “Roh Sung-il, a hospitaladministrator and specialist in fertility who worked
directly with Hwang, said his colleague had
admitted there were fabrications in the second
study on tailor-made human stem cells” (Reuters
news, Dec. 16, 2005). Schatten, the senior author of
the paper, has pointed to the possibility offabrications in the study, and has asked to withdraw
his name from the authorship of the paper. Hwang
has defended his research, but still he says that hewill ask the journal Science to withdraw the paper
due to “fatal errors and loopholes in reporting thescientific accomplishment” (AP news, Dec. 17,
2005). Dean of the Medical Centre, where Schatten
works, has ordered an enquiry in this case. A South
Korean panel has conducted an enquiry into thework of Hwang and his team. Roe Jung-hye, thechief of the Seoul National University’s research
office has said, “It is the panel’s judgment that
Professor Hwang’s team does not have thescientific data to prove that they (patient-specificstem cells) were made.” (Reuters news, Dec. 29,
2005). Hwang now faces possible criminal charges.
A recent exposure of a scam is in a book, “Birds
of South Asia: The Ripley’s Guide” by Pamela C.
Rasmussen and John C. Anderton (reviewed by
Grimmett, 2005). Preparation of this book was
initiated by the great ornithologist Dillon Ripley,
and in this work he was assisted by Rasmussen andAnderton. Ripley died in 2001, and his two
associates completed the book. Rasmussen did nottake the data, available to Ripley, for granted, andworked “from scratch” (Grimmett, 2005), andreviewed such details as distribution, identification
features, extinction/survival etc.. She visited
different museums and examined various
collections, using x-raying specimens and otherforensic techniques, where she felt they werenecessary. In this process she came to discoverfraudulent work of two ornithologists of the first4

Eubios Journal of Asian and International Bioethics 16 (January 2006)

half of the last century, T. C. Stuart Baker andRichard Meinertzhagen.
The British colonel Richard Meinertzhagen,primarily a soldier and a globe trotter, also tried to
be an ornithologist, and in the last role he was
fraudulent. In words of Rasmussen (as quoted by
Barbara, 2005) “There are hundreds and probably
thousands of fraudulently catalogued specimens.
This was going on for the better part of his(Meinertzhagen’s) life”. “… Rasmussen and PrysJones found that, as early as 1914, Meinertzhagen
was stealing specimens from the British Museum
and other institutions, then retagging them withcatalogue details of his own making” (Barbara,2005). Meinertzhagen often changed the label ofstolen specimens. “In one case, he took a specimenof the king-fisher Alcedo hercules that had beenfound on the island of Hainan off China, and listed
it as being from Myanmar” (Barbara, 2005).
Such frauds definitely hamper progress ofscience. There are codes, guidelines and principles
for scientific research. Religion may also help as aprophylaxis against the malady of such scams. A
religion, any organized religion, has a strong ethicalcomponent, which teaches truthfulness andreliability.
Unfortunately of late a controversy has been
spreading among people in some parts between
science and religion. Theory of organic evolution
has been challenged, and teaching of “intelligent
design” side by side with evolution has been
advocated. Intelligent Design is obviously based on
creationism in Genesis in the Bible, As Dawkin and
Coyne (2005) have pointed out, Intelligent Design
is “simply creationism camouflaged”. Almost allscientists do not approve this mix up of science andreligion, which are two different approaches ofhuman mind. The Rev. George Coyne, the Jesuit
Director of the Vatican Observatory has
categorically declaredthat “Intelligent Design
isn’t science, even though it pretends to be”. He has
also said that teaching of Intelligent Design alongside evolution is “wrong”, and is like mixing apples
with oranges (ANSA News Agency Report, 2005).
But, in spite of this controversy, most scientists
believe in religion (as pointed out by Francis S.
Collins, the acknowledged leader in human genome
study, cited by Deanin, 2005), though they takescience and religion as non-overlapping areas.
Some of them, due to their preoccupation with
science, have not taken religion seriously. Even
those, in the latter category, should have had some
exposure to their respective religions, at least in

their childhood, before getting involved inscientific pursuits. Let us hope that taking religion
more seriously would help avoiding such scams.
Those, having aversion to the adjective “religious”
may realize that religious ethics are actually social
laws, in absence of which the social structure
cannot function smoothly. Even social bees havetheir own behavioral code.
I believe that religious training or realization ofneed of social ethical norms will prevent workers in
the field of science from allowing their personal
ambitions to overpower their social obligations. But
the caution, underlying this statement, is only
poorly needed, as almost all scientists are ethicaland honest in their approach, and scams are
extremely rare.
References
ANSA News Agency report, 2005. Vatican astronomer:
Intelligent Design is not Science. November 18, 2005.
Barbara, Santa, 2005. Ornithologists stunned by collector’s
deceit. Nature, 437 (September 15, 2005): 302 – 303.
Dawkins, R. and Coyne, J., 2005. Accepting “intelligent
design” in science classrooms would have disastrous
consequences. The Guardian, UK, September 1, 2005.
Deanin, Cornelia, 2005. Scientists speak up on mix of God
and Science. The New York Times, August 23, 2005.
Grimmett, R., 2005. Taking flight (A review of the book
“Birds of South Asia: The Ripley Guide”, by Pamela C.
Rasmussen and John C. Anderton, published bySmithsonian Institution/Lynx Edicions, 2005). Nature,
438(Dec. 15, 2005).

Multicultural medicine: ethicalissues encountered whenperspectives differ- Karolyn White
Centre for Values, Ethics and the Law in Medicine,
The University of Sydney
NSW 2006, Australia
Email: kwhite@med.usyd.edu.au- Catherine McGrath, The University of Sydney- Ian Kerridge, The University of Sydney
The popularity of therapies collectively
known as Complimentary and Alternative
Medicines, known by the acronym CAM, isincreasing in the developed world. The use of
CAM by terminal patients is particularly high(Chou, et al.). Moreover, the majority of patientsusing CAM do not inform their conventional doctor
about their CAM use.

Eubios Journal of Asian and International Bioethics 16 (January 2006)
In this paper we explore the case of one
patient that highlights the ethical problems of
multicultural medicine that are infrequently
acknowledged in the literature and discusspossible ways of resolving these.
The combined use of allopathic medicine andCAM by patients is paradoxical as the two systems
areontologicallyandepistemically
incommensurable. It is our contention that thisincompatibility is irrelevant to patients provided it
causes no conflict between their orthodox andalternative practitioners. We recognise thephilosophical incompatibility, but maintain this has
little bearing on their treatment. However, theincommensurability does become salient undercertain conditions. It is these conditions we wish to
discuss in this paper.
Patients with a terminal disease use CAM for
fairly specific reasons. These include wanting to
try absolutely everything possible, dissatisfaction
with conventional medicine including theimpersonal nature of the patient-practitioner
relationship, the lack of time practitioners spend
with patients, to mitigate the side effects of
conventional treatments particularly chemotherapy
and radiotherapy and for cultural reasons.
And now for Norah’s story.
“Norah is a young woman, married with twochildren. She lives in an extended family situation,
congruent with her culturally Chinese background.
Sadly, Norah has lymphoma. She has alreadyundergone aggressive chemotherapy, and stem celltransplantation, which have failed. Throughout her
illness, she has received traditional Chinese
therapies, as well as conventional treatment,
without any sense of conflict between the twosystems.
She becomes progressively worse. Breathing
becomes increasingly difficult because of thelymphoma in her neck, she is anorexic, and she
feels permanently tired and listless. On meetingwith her haematologist her treatment alternatives
are discussed. The consultant recommends Norah
have a donor stem cell transplant from her sister.
After being given an anti-inflammatory medication
to improve her breathing, she goes home to tell her
family and to prepare for hospital.”
At home, her family tell her they have found a
Chinese practitioner visiting from Hong Kong. He
consults with Norah and palpates her neck; he thenrecommends a regime of Chinese herbs and dietand tells her to be even and calm. From theinformation he gives her, she understands that she

5is sick through no fault of her own, she is sickbecause of the legacy of her ancestors. His
explanation of why she, and no other member ofher family, is sick, his theory of causation, is really
important to Norah. Her Chinese practitioner also
tells her he can cure her in three months, but only
on the condition that she give up all western
medicine. Norah cancels the impending stem celltransplant.
While the epistemological and philosophicalincommensurability has not mattered until now –Norah has been using CAM for the last 12 months
with no therapeutic problems – the decision by the
Chinese practitioner to tell Norah to stop all
Westerntreatment
has
made
the
incommensurability salient.
Ethically, Norah has been subjected to greatpressure to forgo conventional treatment because
the Chinese practitioner cannot cure her unless she
abandons Western medicine. Norah has been
losing faith with conventional medicine since thelast stem cell transplant failed to cure her. Since
then, she has been searching for answers to thequestion that so many people with potentially fatal
diseases ask – “Why me?” Her new practitioner
has now given an answer she can understand andmoreover she can plan for her future.
The decision by the Chinese practitioner totell Norah to put a halt to conventional medicine
has also created ethical dilemmas for the treating
oncologist and bone marrow transplant physician.
The conventional practitioner’s responses to thesituation have been limited by the circumstances.
We suggest there are 3 responses open to theconventional practitioner, assuming he wants thebest for Norah and assuming he maintains that her
best option is to have a stem cell transplant in thenear future. His first response is to objectively tellher the options and to let her know the implicationsof her choice. Ethically, this option emphasizes
patient autonomy and the ability to make rational
choices. The practitioner’s responsibility is toprovide the information on which the patient canbase a rational choice. It ends if the patient’s choiceseems irrational to his judgment.
The second response is more paternalistic.
The practitioner acts from the ‘best interests’position. He informs the patient of her options
then urges her, more of less strongly, given his
personality and how far he believes he can push therelationship, to reject the Chinese practitioners
treatment because it is harmful and to accept
conventional medicine. He may even decide to6

Eubios Journal of Asian and International Bioethics 16 (January 2006)

speak to her relatives and enlist their assistance toconvince her of the error of her treatment ways.
The third possible response is from a broadly
feminist understanding of the importance of
maintaining relationships.
Her conventional
practitioner does all he can to convince her of theimplications of her decision, but unlike the first
response he does not sever the relationship when
the patient chooses the alternative treatment, andunlike the second response he does not insist heknows what is in her best interests. Instead he
attempts to maintain the relationship and to viewthe illness and treatment from Norah’s perspective.
By maintaining the relationship and not abandoning
her, he ensures his presence for her if and when, in
three months, she is not cured as promised by her
CAM practitioner.
Each response has its problems. To privilege
autonomy is to neglect the reality of dependency inillness(Campbell,1994).
To
practice
paternalistically is to privilege one world view in apluralist society. The feminist approach can be seen
as a means of opting out of personal judgment andresponsibility for the welfare of the other in orderto privilege continuing communication. Each
option brings potential moral dilemmas to bothpractitioner and patient. Each exposes theimportance of trust and continued negotiation, andthe need for continuing re-examination of whatcounts as a good outcome for both patient andpractitioner.
In our case the conventional practitioner
responded to his patient from the feminist position.
He saw Norah weekly and supported her decision.
He also monitored the tumour and blood studies in
the knowledge that this information was allowing
her CAM practitioner to keep abreast of her
situation from Hong Kong.
This response allowed for the ongoingdevelopment of his relationship with Norah. At thesame time, it created a deep uncertainty for thephysician as to the morality of endorsing an
unproven treatment when a potentially effective
one was available. Both other responses would
have seen Norah break off the relationship and, we
conjecture, dispense with conventional medicine
altogether. Norah would be hard pressed to findanother suitably qualified specialist who would be
willing to see her without insisting on conventional
treatment and a stem cell transplant.
In multicultural Australia, dilemmas such as
this are becoming more common. CAM andconventional medicine usually coexist quite

peacefully. Problems occur when a practitioner
from one system forbids the other system, andthreatens to withdraw from care unless the patientcomplies with his or her instructions. This places amoral burden on both the excluded practitioner andthe patient. When the patient makes a choice forone system or the other, the excluded practitioner
can respond by privileging the patient’s autonomy,
by offering paternalistic advice about perceived‘best interests’, or by a feminist privileging ofcontinued relationship. None of these alternatives
provide completely satisfactory solutions in every
case.
References
Campbell, A. V. (1994). Dependency: the foundational value
in medical ethics. Medicine and Moral Reasoning. K. W. M.
Fulford, G. Gillett and J. M. Soskice. Cambridge,
Cambridge University Press: 184-192.
Chou, JC. Horng, PM. Tolmos, J. Vargas, HI. ‘Alternative
therapy use by breast cancer patients’ Medicine of theAmericas 1:1 p.26

A Book on Medical Ethics inMedieval Islam: Al-Tashwîk AlTibbî (Encouraging Medicine) of
Abu’l-Alâ Sâid B. Al-Hasan AlTabîb (1009-1087 A.C)
- Ahmet Güner, Ph.D.
Dokuz Eylül University, Faculty of Divinity,
Hatay, İzmir, Turkey
Email: ahmet.guner@deu.edu.tr
As it is known that “Medical Ethics” had gone
through long process of development until it
became a particular medical discipline with its own
unique character in the Islamic medical tradition.
One of the most prominent characteristics of thisprocess that continued from 9th century up to the16th century is that several works on medical ethics
were produced.
In 1071, in a city called Rahbah situatedbetween Baghdad and Raqqa, a book written by
Abu’l-Alâ Sâid b. al-Hasan al-Tabîb with the titleof Tashwîk al-Tıbbî was added to existing literature
on Islamic Medical Ethics. Thus, this paper aims at
first introducing the author who is not wellrecognized by many in the field, and then analysing
the content and various aspects of the work itself.

Eubios Journal of Asian and International Bioethics 16 (January 2006)
1. Sâid b. al-Hasan al-Tabîb, the Author of AlTashwîq al-Tıbbî
Although we have some scanty information
about his life, Abu’l-Alâ Sâid b. Al-Hasan, thewriter of al-Tashwîq al-Tıbbî, was most probably
born in Rahba in Iraq and might have lived sometimes both in his home town and as well as in Syria
between 1009-1087 (A.C.). From the biographicalsources and also from his own writings one would
get the impression that he was well-educated inmost of the philosophical sciences of the time andhe seemed to be well-known physician with amastery of other sciences such as astronomy,
linguistics and literature. As testimony to his
extended interest in and also to the depth of his
knowledge in other sciences it suffices to mention
another work of Sâid b. Hasan, al-Tashwîq alTa‘lîmî (Encouraging Education), an introduction
into astronomy for students. Sâid b. Hasan’sscientific career resulted also in his manifest
interest in various mechanical tools designingwhich might still very well capture ourcontemporaries’ attention. The historian Ibn Asâkir(d. 1176 A.C.) records that he built a lifting device
for heavy stones, and he also made iron ink-penswhich could be used, when filled, a whole month
before ink dries. We also learn that he received theprotection from many Arab and Salcuqî rulers. In
short, he seems to be a good representative of his
era when the civilisation of Islam was at its apex.
Many famous physicians, philosophers andscientists of this age such as Ibn Sînâ (d.1037
A.C.), al-Bîrûnî, Miskawayh (d.1030 A.C.), İbn alHaytham (d.1040 A.C.), had lived within the sameor close generations. It might be added that he wasan intellectual sensitive to requirements of his age.
2. A General Overview of al-Tashwîk al-Tıbbî
Some thoughts on the implications of the title of thework, Encouraging Medicine
The first thing that draws our attention is thetitle of the work, which is both rare and interesting.
The author’s reasons for choosing such a title must
relate to the aim he intends in writing it. Thus, inseveral places in the work the author indicates thispurpose. On the one hand, he tells us, that he hastaken notice of the many wrong medical practices
and terrible effects of these kinds of practices
suffered by people in Mesopotamia and Syria at thehands of under-instructed, uneducated physicians.
On the other hand, we are told that he wrote thiswork in order not only to show what the realscience of medicine is all about and what it means

7

to be a real physician, but also to encourage eligible
individuals with a quick wit, intelligence and good
motivation into learning the science of medicine aswell. Indeed, a general overview of the bookreveals to us that the work was actually intended to
be a voice encouraging the people to learn theauthentic science of medicine and its proper
practices.
The significance and place of the work in theIslamic literature on Medical Ethics
The second important point is how todetermine the significance and position of the workwithin the Islamic literature on medical ethics.
There are numbers of works known that are related
to medical ethics beginning with those by Yuhannab. Mâsavayh (d.857-58 A.C.), Hunayn b. Ishaq (d.
878 A.C.) and so on, continuing with a treatisecalled Akhlâqu’t-Tabîb by Abû Bakr al-Râzî (d.
925 A.C.), which is available today. Finally, Ishaq
b. Alî al-Ruhâwî, who lived between the second
half of the ninth century and first quarter of thetenth century in Şanlıurfa, Turkey, wrote the firstsource book covering all important issue of medical
ethics. Thank to this magnum opus of Islamic
medical ethics, “Adab al-Tabîb” it was possible forscholars to determine the boundaries and subject
matters. During the ages following this pathbreaking work until the appearance of al-Tashwîq,even though there were several other importantbooks in medical ethics also authored by wellknown physicians, none of the these previous
works reached the status of a standard book of
medical ethics in terms of content, method,
systematic and style. For this reason, al-Tashwîq
deserves to be regarded as the most significant
work seconded only by Ruhawi’s work in thehistory of Islamic medical ethics until 12th century.
Content and method of the work:
The third important point to be noted is theextent and method of the work. Covering almost all
major issues of classical Islamic medical ethics, alTashwiq was written in a style and method thateven a modern scholar might find at the least
unfamiliar. Briefly, the work is divided into thirteen
chapters, an introduction and a conclusion included.
Each chapter linked with the others in terms oflogical order and content. Furthermore, any
attentive reader cannot fail to observe theobjectivity, rationality and persuasiveness of thearguments developed in the work.
Language and the style of al-Tashwîq:The work is also important in its linguistic andstylistic features. One of the easily and distinctively

8

Eubios Journal of Asian and International Bioethics 16 (January 2006)

recognizable features of the work is that it is
written with a fluent and captivating language andmanner. In other words, the work testifies its
author’s literary prowess and competence.
Its sources:
Regarded from another angle, the work also
proves that the author has at his disposal a variety
of sources ranging from Greek medical authorities
such as Hippocrates and Galen, and to texts of
Quran and Hadiths related to medicine, to historicalnarratives of medical importance, and mostsignificant of all, from his own observations andexperiments to the cases reported by others in thefield. We can also note that to certain extent theauthor makes references to his sources, but othertimes sometimes he fails to do so, leaving thereader at a lost about possible sources.
A Short summary of the content
After the general evaluations of various
aspects of al-Taswiq, I may now briefly describe its
content. Following the first chapter serving as apreface, the second chapter begins with an
explanation of the importance of science of
medicine and its high value among other sciences.
The subject matter is further established withrational, experimental, social, religious-cultural andnatural proofs.
The third chapter draws a list that includes
mental, physiological, moral, religious, scientificand professional qualifications required of a
successful physician. These qualifications can be
described as follows. A physician must have a highintellectual capacity and perception, powerful mind
and memory, devotion, good temperament, goodheartedness, honesty and reliability, compassion
and modesty; avoid indulgence in wealth, lust andintoxication; must also have adequate formation insciences, be able to unite theoretical knowledge
with practical and have clinical education in thehospitals, to continue in scientific and medical
research, and atone himself to the medical
purposes.
In chapter four, the author surveys basic
medical sciences and auxiliary sciences that aphysician should learn. He regards the following
sciences as complimentary to medicine: logic,
arithmetic (hisâb), geometry, optics, astronomy,
music and geographical medicine. The basic
medicine sciences included are as follows: schoolsof medicine (fıraq al-tıbb), science of elements(ustukussât: soil, water, air, fire), humeral
pathology (ahlât), science of temperaments,

anatomy, illnesses, diagnostics and treatment (ilmal-amrâz), taqdima al-ma’rifa (development of
illnesses in time) and pharmacology. In thischapter, the writer also emphasizes that thephysician should practice both the method of
analogical reasoning and the experimental method
in diagnosing and treating illnesses. These two
methods were defended by two classical schools of
medicine independently from each other.
The fifth chapter deals with guidelines
followed by a physician both in his private andprofessional life. Here the author engages in a long
discussion about these rules of conduct thatphysicians must adapt. Some of guidelines thatwere treated in detail are: First of all, the physician
should comfort his patient before asking some
information about the developments of his illness.
He should try advice the patient a food andvitamins diet first, before making his decision fortreatments with medicines and with medical
operation. Furthermore, in order for a physician to
become an expert in his profession, to get good
medical education, to acquire knowledge about new
and unknown illnesses and to continue his career hemust be related to, or work in, hospitals. The
privacy of patient must observed and secrets ofpatient related to his illnesses must be kept
confidential. He must abstain from preparing
poisonous and fatal substance.
The sixth and seventh chapters are devoted tomalpractices of so-called physicians who are either
under-educated or hoaxers. Thus, here people are
averted against receiving treatment from suchinsufficient practitioners. The chapter eight entitled“examining physicians” contains several questions
in order to test aptitude of physicians in various
medical subjects and to determine whether he isreal doctor. The content of the ninth chapter
consists of the factors that affect diagnostic failures
and liabilities of physicians. In this chapter, thewriter enumerates and examines the following
causes for possible failures: faults due to physician,patient, person accompanying a patient or nurse,
and external conditions.
The writer, in the tenth chapter draws
attention to false conceptions of medicine
perpetuated by ill-educated physicians among thecredulous public. In the eleventh chapter, some
practical information on protecting health(preventive medicine) and diagnosing common andsimple illnesses (qânûn hıfz al-sıhha) is given. It isclear that the writer’s aim here is to contribute to
the education of society in protective measures andEubios Journal of Asian and International Bioethics 16 (January 2006)
in avoiding wrongful practices or in getting selfassistance for those who live in places where there
are no physicians. The twelfth chapter narrates
various stories. These are generally related to some
unusual medical case stories or incidents he has
personally witnessed, read, heard from others. The
book ends with a call inviting able persons to get an
education in medicine and with an emphasis on thesignificance of medical science for human life.
As a conclusion, although the work may havelost some of its value under the passing history,
both in content and effectiveness of proposedsolutions of some medical problems, today it still
remains a relevant guide for us in medical ethics. It
is absolutely clear that as modern readers, if we areopen enough to its deeper voice, we can still easily
understand his book and we can find the author as
one of our contemporaries who shares his precious
insights on ethical issues with us.
ReferencesAbû Bakr al-Râzî, “Ahlâq al-Tabîb”, in Sitt Rasâil min alTurâs al-Arabî al-Islâmî, ed. Abdullatîf Muhammad al-Abd,
Cairo 1401/1981, pp. 119-149.
İshâq b. Alî al-Ruhâwî, Adab al-Tabîb, ed. Murayzin SaîdMurayzin Asîrî, Riyad 1412/1992.
Abu’l-Alâ Sâid b. al-Hasan al-Tabîb, al-Tashwîq al-Tıbbî, ed.
Murayzin Saîd Murayzin Asîrî, Riyad 1996.
Murayzin Saîd Murayzin Asîrî’s study on al-Tashwîq and his
author Sâid b. al-Hasan, in al-Taşwîq al-Tıbbî, pp. 21-46.
Ibn Asâkir, Tahzîb Târîh Dımaşq al-Kabîr, Beyrut 1979, VI,
p. 362.
Ibn Abî Usaybia, Uyûn al-Anbâ fî Tabakât al-Atibbâ, editedby Nizâr Rizâ, Beyrut undated, pp. 90, 272, 255, 277, 316.

Confucian Ethics: Responsibilities, Rights, and Relationships- David Cummiskey, Ph.D.
Professor, Philosophy Department
Bates College, Lewiston, Maine, USA
Email: dcummisk@bates.edu
Confucian ethics focuses on the structure ofhuman relationships, and in particular on the core
relationship of the family. Indeed, the family is
supposed to provide an idealized model for all otherrelationships. The classical Confucian conceptionof social and political philosophy is also morehierarchical and paternalistic than modern western
approaches. As a result, there has been significant
contemporaryAsian
opposition
totheindividualism of Western rights-based approaches
to ethics and political philosophy. Indeed, some9argue that the “rights pollution” of Western moral
and political philosophy fundamentally distorts anddestroys naturally harmonious human relationships.
In this article, we will evaluate these aspectsof Confucian ethics, carefully consider theConfucian objections to rights theory, and develop
a model of the Patient-Physician Relationship thatis reflects the best of Confucian ideals. We will
first discuss the basic ethical principles ofConfucian thought, including the “five basic
relationships” that are at the core of day to day
moral life.(1) We will then turn to issues in moral
psychology and the contemporary Confucian
critique of rights theory. Although, the critique ofrights theory is mistaken in important ways, it isalso the case that the Confucian emphasis on thecentrality of relationships is often missed by recent
rights theory. We thus conclude by developing amore relationship-based, family-centered, andegalitarian model of the “Physician-Patient”
Relationship.
1. The Five Basic Relationships
Confucian ethics includes all of the customs,
manners, habits, conventions, and indeed all of theordinary behavior of daily life. In Confucian
philosophy this is characterized as the following ofLi, which is protocol, etiquette, propriety, andritual. The principle of Li is simply acting inaccordance with conventionally recognized rightbehavior.
Li, of course, also includes theappropriate behaviors of rulers and subjects, andthus the principles of good government andcitizenship. The other Prime Virtue of Confucian
thought is Ren (or Jen), which is benevolence andhumaneness. The cultivation of Ren is essential tohuman virtue and excellence. Ren and Li are
intimately connected: Ren as humanness andbenevolence guide and shape social conventions
and the principles of Li (Propriety); and, on theother hand, Ren, which is humanness andbenevolence in one’s dealings with others, is only
realized through all of the daily practices and ritualsof life. Li is blind without Ren, and Ren is empty
without Li.
Closely
relatedtoRen(Humanness/benevolence) is the Confucian
principle of Reciprocity.
All natural social
relations involve mutual benefit. Indeed, like all of
the major religious traditions, Confucians have a
version of the “golden rule” : “What you do notwant done to others, do not do to others.” It isinteresting that the principle is not focused on one’s

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Eubios Journal of Asian and International Bioethics 16 (January 2006)

self but on what one does not want done to others,
and here we perhaps see a deeply relational, nonindividualistic element in Confucian thought – treat
others, as you would want them to treat others –which we will discuss below.
Within the context of the broad principles of Li
and prime virtue of Ren, the ideal Confucian person(Jun-zi) is further defined in terms of idealizedsocial relationships that include a “natural”
hierarchy that is assumed to be part of all social
relations. The most basic of all social relationships
is the family, and thus the central of all Confucian
virtues is Filial Piety: respect for ancestors, parents,and elders generally. There are, however, Five
Basic Relationships, each with its distinctive role
related virtues:
Relationship:
Distinctive Virtues:oFather and son (Parent and child)–affection, filial respectoHusband and wife–
separate gendered rolesoElder brother/sibling and younger– order,
proprietyoRuler and minister/subject–
righteousness, justice, loyaltyoFriend and friend–
faithfulness, fidelity
These five basic relationships are the natural social
relationships that essentially constitute humansocial life. In there classical formulation, the Five
Basic Relationships are strongly gendered leavingout daughters and sisters, and including only wives.
The first relationship can be expanded to ParentChild and third can be recast as Siblings, but thehusband-wife relationship is clearly conceived as
defined in gendered terms. Altering it to SpouseSpouse is a substantial change, and thus it will
receive a more substantial discussion below.
Internal to each relationship are specific roles,
responsibilities and virtues that are based directlyon the nature of the particular relationship:• Parent and Child: A parent owes a childaffection and care, an education that promotes
intellectual and moral development; a child owes aparent obedience, respect, and care in old age andafter death. The parent-child relationship naturally
and spontaneously includes an emotional bond oflove. The authority of the parent is rooted in
wisdom and aimed at the good of the child. A
child’s respect for parents, and family elders, isessential to social order and virtue. Filial Piety isthus the core virtue that defines and shapes most of

one’s life. (Filial piety includes respect for one’s
ancestors and is clearly related to ancient ancestor
worship.)• Husband and Wife: The husband is to lead,provide for, and protect the family; and the wife isto maintain the household and defer to her husband.
The family is lead by the father. Gender relations
involved ritualized and clearly defined female
subordination, and this leads to a culturalpreference for sons over daughters. The ideal
Confucian woman is deferential, silent, and, ofcourse, fertile. Her virtues are inner strength,
forbearance, and a calm restraint.
• Siblings: The older brother/sibling is to lookafter the younger and to help the younger to obey
and internalize his social roles and to fit well into
the overall life of the community. The younger
supports, shows deference, and respects the older.
• Ruler and Subject: The ruler is like abenevolent parent and the subjects owe obedienceand loyalty. Unlike the parent-child relation, thenatural bond is not affection and love; instead, it isa sense of justice and righteousness. Since the Ruleof Law cannot be arbitrary or lawless, the subject
should be able to respectful express dissent whenappropriate. Ideally the Ruler should command
obedience by example rather than by coercion andforce. The resort to force always signifies failure.
If the state is well ordered and the ruler is upright,
obedience is natural.
“Lead the people withadministrative injunctions and put them in theirplace with penal law, and they will avoid
punishments but will be without a sense of shame.
Lead them with excellence and put them in theirplace through roles and ritual practices, and in
addition to developing a sense of shame, they willorder themselves harmoniously.” (Analects) Rulers
should always pick the most able, virtuous andqualified to succeed them, and not their own eldest
sons or family members. In this case, State piety ishigher than any filial obligation.
• Friendship: Mutual loyalty aimed at mutual
virtue is the essential virtue of friendship.
Friendship is based in virtue and contributes to selfdevelopment. Friends are akin to brothers: “Whenat home, you have your brothers; when abroad, youhave your friends” “For men with no brothers, there
are none who have established themselves who
have not had friends to help them.” “Truefriendship is a plant of slow growth, and must
undergo and withstand the shocks of adversity”(Analects)

Eubios Journal of Asian and International Bioethics 16 (January 2006)
Friendship is the anomaly here. The central
place of filial piety or respect, honoring anddeferring to paternal authority, is the central anddistinctive virtue of Confucian thought and, it
clearly provides the hierarchical model for the otherrelationships. In addition to husband and wife, andruler and subject, other basic social relationships
like employer-employee or teacher-student, areunderstood to have a similar hierarchical,
paternalistic but benevolent structure. In addition,
the deference to elders and superiors is recognizedin all relations through a respect for a hierarchy ofage and accomplishment that are always shown
respect.
Although the emotional bond and mutualcommitment of friendship is essential to it, in later
neo-Confucian thought the pure reciprocity andequality of friendship is often minimized, andindeed a hierarchical element is added oremphasized. The neo-Confucian Wang Youliang(1742-1797), for example, in “Correct Friendship”
claims that brothers, like a family of geese,naturally fly one behind the other, and so too thesame hierarchical harmony should apply in the caseof friends. Friends are also thought of as akin toteacher and student: “When three people move
together, surely there is one who can teach”(Analects).
These points, however, are notinconsistent with an egalitarian conception offriendship: friendships founded on equality andreciprocity are fully compatible with the fact thatfriends often learn from each other (as teacher andstudent) and that it is often best for one friend tolead the others (breaking the way like a family ofgeese one behind the other). In a friendship ofequality it is simply the case that the roles ofteacher and student are fluid and changing withcircumstance. I may teach you philosophy and you
may teach me art history. I may teach you to sail aboat and you may teach me how to fly fish. You
may teach me patience and I may teach you
courage. Similarly, like geese or bike teams, we
may alternate leaders of the flock thereby taking
turns breaking the wind for the mutual benefit of all(2).
Friendship seems to stand out from the otherrelationship because it is a voluntary relationship,
and unlike filial bonds, particular friendships do notseem to be “decreed by heaven.” The relationshipof children and parents, and siblings are largely
unchosen roles that come with responsibilities. The
relationship of husband and wife also seems to haveclear elements of a “natural” relationship, and there11

is a “natural” basis in child bearing and nursing fora division of social roles and responsibilities. The
hierarchy of authority and deference, emphasized in
traditional conceptions of marriage, however is nota necessary aspect of gendered parenting. In
addition, particular spouses are no more decreed byheaven than are friendships. Of course traditionalarranged marriages are often decreed by parents,
and thus are also unchosen relationships withresponsibilities. But conventional social practices,
however common, are not in any normative sensepart of the natural order of things.
The reciprocity and equality of friendshipstrikes many as an inherent and natural reflection of
the nature of the friendship relation. Furthermore,friendship is essential to a flourishing human life; it
is a truly deep and essential aspect of humanexistence. More generally, it is in the nature ofthings for equals to treat each other with mutual
respect, not asymmetrical deference – an attitude ofdeference to one’s equal is itself unnatural.
Friendship, with its robust equality, mutuality, andreciprocity, is a core and natural human relationshipthat lacks the characteristic paternalistic authorityof the parent-child “Paternal Relationship.” Forlack of a better term, let us call the core elements ofthefriendshiprelationan“Egalitarian
Relationship.”
2. The Psychology of Moral Development
Let us grant that paternal authority, paternalismand deference, is natural and appropriate to thePaternal Relationship. We have seen that equality,
reciprocity, and mutual respect are natural andappropriate to the Egalitarian Relationship. The
question is thus whether a paternal model is also
appropriate to the Spousal Relationship and thePolitical Relationship? Or do they instead naturally
partake of core elements of the equally naturalmodel of the Egalitarian Relationship, or somemodel particularly suitable to their particularnature?
Why think that the hierarchical Paternal
Relationship is the paradigm for all relationships(so that the friendship relation is the anomaly)?
Here is the most common argument for the primacyof the parent-child relationship:“for Confucians, only through the establishing,nurturing, and developing of the parent-child lovein the family and gradually extending it to otherpeople outside the family can a good society bepossible. Hence, love must begin from the parent-12

Eubios Journal of Asian and International Bioethics 16 (January 2006)

child tie inside of the family. If it cannot begin
from the family, it will begin from nowhere.” (3)This argument begins by quite rightly
emphasizing the importance of the parent-childrelationship to psychology of moral development.
The argument further assumes, however, that if
moral development begins with familial love, thenthis model of love must also be the basis of allsocial relations, and thus the inequality of status
and the hierarchical paternalism definitive ofparental love must also characterize all other social
relations. But this does not follow at all. It isclearly the case that moral development begins in
the unequal and hierarchical relation of parent andchild, but it does not follow that moral development
also ends here; and it also does not follow that this
distinctive primary inequality characterizes idealsocial relationships.
Indeed, the parent-childhierarchy and inequality is most obviously based on
the lack of capacity of infants, children, andadolescents. Similarly, as people develop fromchildren to adults, the relations change to reflect theincreased capacity and realization of humanpotential. Without the actual distinction in realized
capacity, and the original need to nurture moral
development, the paternalistic hierarchy would not
be justified at all. So from the inequality at the startof moral development, a presumption in favor of an
inequality of citizenship status, between mature andcompetent adults, simply does not follow. What
could be clearer?
The Confucian, and also traditionally Western,modeling of ruler-subject relations on the model ofhierarchical relationships essentially involves thefalse infantilization of adult citizens. In thecontexts of widespread illiteracy that has existed
for most of human history, perhaps the assumptionof the greater competence and wisdom of theeducated ruling classes may have been justified.
Indeed the examination system provided a clear
basis for deference based on education, training,and expertise. But in a modern society with awidely literate or otherwise well informed public,
this model distorts reality by treating adults ofroughly equal capacity as unequals.
The model of paternal, hierarchical, politicalauthority is thus often no longer justified, however
deeply rooted in ancient traditions it may be. The
contrast here importantly is not one of Eastern andWestern thought. The West also has a long
tradition of political authoritarianism combinedwith class inequality and aristocracy. The western
philosophical tradition was rooted in Plato’s

idealized Republic of Philosopher-Kings (“SageKings”), Aristotelian Aristocracy, and the Divine
Right of Kings. Even the West more recent
recognition of the “Natural Rights” long coexistedwith slavery, paternalistic colonialism, racial
segregation, a landed gentry, and the legal
subordination of all women. The doctrine ofuniversal human rights marks a break from theclassical past and a distinctly modern conception of
the nature of citizenship. The difference in theclassical and modern models is a clear issue of
substance to be settled by reasoned analysis. This
is not simple cultural difference; it is an objective
philosophical issue to be settled by the strength ofreasons.
Returning to the issue of substance, what is therelationship between the initial morality rooted inpaternal love and the moral relations of mature andcompetent adults? Contemporary psychology has
posited clear stages of intellectual and moral
development. The principles of moral psychology
suggest that we go through an initial stage
characterized by a morality of authority, next thisdevelops into a morality of associations, which inturn is transformed into a morality of principles(4).
Here is a brief summary of this model of moral
development:
The Morality of Authority: in a context in which
parents treat children fairly and the parents love thechild and manifestly express their love by taking
care of the child and protecting the child, then thechild will recognize the parent’s love and will loveand trust the parents and also will look up to theparent as source of comfort and safety. The childthus recognizes the authority of the parent and will
generally obey their rules or percepts that otherwise
constrain the unbridled will of the child. The
morality of authority is manifest in the acquired
internalized disposition to follow the precepts of amore powerful person that has one’s love, trust, andrespect. The motivation is one of obedience tocommand, and not an independent recognition of
the rightness or appropriateness of the commands
in questions. The prized virtues are thus obedienceand deference; the leading vices are disobedienceand audacity.
The Morality of Associations: in cooperative
associations with others, a person who has
developed the capacities for love and trust in thefamily will also develop friendly feelings toward
others in shared associations. If the association isjust and fair, and others intentionally comply with
their responsibilities and duties, a person who has

Eubios Journal of Asian and International Bioethics 16 (January 2006)
developed an initial disposition of obedience toauthority will naturally develop a disposition towant to do one’s fair share in the cooperative
scheme too, and will thus be disposed to take on afair share of responsibilities. We naturally careabout the approval and disapproval of others withwhom we are associated, and are thus motivated toearn the approval of others. In associations,
including the original association of the family, themembers have different roles with distinct
responsibilities. From our role in the family we are
already familiar with the nature of role-specificresponsibilities. As we grow we learn the specificchores of the child, and next the responsibilities ofa student.
This sense of one’s place in acooperative association involves understanding thedistinct responsibilities and perspectives of thedifferent roles, and this essentially includes theability to see a situation from multiple perspectives.
It also involves recognition that the benefits ofsocial life require cooperation, mutual sacrifice, andmutual responsibility. The morality of associationis rooted in an original motivation to please others
and to fulfill one’s distinctive role; it develops,
however, into a nascent sense of fairness,
reciprocity, and equity.
The Morality of Principles: The last stage ofmoral development involves a fuller recognition ofbasic principles of justice and morality. In the final
stage of moral development, a commitment toreciprocity itself and to the good of others
supersedes both the original morality of authority
and the morality of association based as it isoriginally is on the desire to please others. The
basis of authority is now clearly recognized to bejustified by the good served to those who aresubject to it, or as a source of impartiality, or bysimple organizational utility; and not as reflecting ahierarchy of worth or rank of persons. Similarly
the original simple acceptance of role-based
responsibilities is superseded by a recognition thatassociations must be just and fair, if they are to
obligate us, and thus they must work to serve theinterest of all and respect the equal status of all.
We thus have a natural and progressive
development from the emergence of morality in thecontext of the love and paternal authority of thefamily to an egalitarian morality of mutual respectand mutual concern. The model of friendshipshould thus serve as the ideal moral relation. For
human relations in general, where familial love or
the affection of friendship is out of place, an ethic
of equal concern and mutual respect naturally

13

replaces familial love and mutual affection. An
ethic of care draws us together and makes us
responsive to the interests of others. An ethic ofrespect recognizes the equal status and theautonomy of others and makes us responsive totheir point of view and the interest each has inleading his or her own life. Care motivates helping
and preventing harm to others (that is, principles ofbeneficence and non-malificence); Respectbalances this with a recognition of the value of selfdetermination (that is, respect for autonomy).
Thus when it comes to children, it is indeed
fitting that the older sibling should look out for the
younger. As adults, however, although some of thehierarchy of the original relationship may play aninterpersonal role, equality and mutual care andmutual respect will replace the once naturalinequality. The Husband-Wife relationship with
its traditional gender relations raises more
controversial issues. It is important to divide twoissues: the gendered division of labor and thehierarchy of authority. Whether the traditional
division of labor surrounding childcare anddomestic life is originally and naturally rooted in
the biology of child birth, and breast-feeding, orarises from socialization and patriarchic power
raises much controversy.
The inequality ofauthority, however, is less complicated. The
ideology and rationalization of male authority isinevitably linked to empirical beliefs about female
inequality, and indeed the infantilization of women,that are now widely recognized in the East and theWest to be empirically baseless. Whenever, andwherever, the legal and social barriers to women’s
education and self-development are removed, we
see clearly that the ideology of inequality ispatently false and indeed it was only the elaborate
barriers to women self-development that limited thepotential and possibilities of women. It is clear thatpast claims of a natural female intellectual
inferiority were baseless.
We have seen above, in discussing thefriendship relation, that mutual respect andreciprocity is a natural and indeed an ideal
relationship between equals. This is true forfriendship and it is also true for the relationship ofcitizenship.
Similarly, in the Marriage
Relationship, even if there is a gendered division ofdomestic roles, Confucian naturalism simply does
not lend any support to patriarchy with its
relationship of domination and submission. This is
not to deny the strongly gendered conception of
marriage that is accepted in Confucian culture. The

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Eubios Journal of Asian and International Bioethics 16 (January 2006)

point is first to emphasize that patriarchy
characterizes many traditional cultures, and that it
was just as dominant in Western culture. We havenot explored the basis of traditional genderinequality. We have instead emphasized that if one
rejects arguments based on a supposed natural
female inequality, then a more egalitarianconception of the marriage relationship naturally
follows. There is nothing inherent in Confucian
naturalism with its specific emphasis on roles andrelationships that implies that all relationships
should be hierarchical. This is a cultural tradition
yes, but it is not rooted in any deeper philosophicalinsights of Confucian thought.
To sum up, we have seen that Confucian ethics
rightly emphasizes that healthy moral development
depends on the family in particular and of
relationships in general.
Confucian ethics,
however, has also embraced hierarchy andinequality, including the subordination of women,
and here we have seen that this is mistaken as an
ideal of human relationships, and that it is also
inconsistent with the naturalistic basis ofConfucianism itself.
Contemporary Confucian
ethics is thus right to continue to emphasize thecentrality of relationships to ethics, but it should
also embrace a more egalitarian moral ideal ofthese relationships.
3. Responsibilities and Human Rights
Confucianethicsrightlyemphasizes
relationships.
Contemporary Western ethicaltheory and medical ethics, on the other hand, isfocused on individual rights.
Rights theory is
intimately linked with individualism and thepriority of liberty over other social goods. Indeed,
western liberal theories often define themselves interms of the priority of the right, which means thepriority of individual rights, over considerations ofvalue and the overall social good.
Without
diminishing the importance of claims for the equaldignity and humanity of all persons, the alleged
universality (and superiority) of a fundamentallyrights-based conception of morality appears to be acontemporary liberal conceit. Human rights claims
clearly have their proper place in moral andpolitical philosophy, but it is noteworthy that even
Kant, the patron saint of liberal rights theorists,
focuses on our duties before our rights. In is in oursense of duty and moral responsibility that we
become conscious of the dignity of humanity, heargues.

Confucian ethical theory, with its emphasis on
relationships and responsibilities, provides a
striking counterpoint to contemporary rights theory.
In particular, it helps us see clearly the point andplace of rights claims. The five basic relationships
clearly involve responsibilities and duties, and wehave seen that ideal human relationships arecharacterized by mutual care and mutual respect.
When these relationships are functioning properly
the individuals will naturally make claims on eachother and have legitimate expectations about how
they will be treated, but they need not appeal toindividual rights in pressing these moral demands.
Indeed, in many normal social contexts, rights
claims seem out of place because of theirindividualistic emphasis.
For example, rights-claims are particularly outof place in certain social contexts like team sports
and dance troupes (5).
In these contexts,
participants have roles that are typically assignedon the basis of talents and abilities, and they must
coordinate their behavior in order to accomplish ashared goal or activity. On a basketball teamplayers have roles and specific tasks, and clear
grounds for complaint when a player does not act
appropriately. The point guard may be responsible
for getting the ball inside to the center, and theother players may be critical if the guard keeps
shooting from outside, but it would be mistake forthe center to object that she is being denied herright to the ball. The failure here does not involve
the violation of individual rights.
The
responsibility is to the team as a whole and theviolation involves not doing one’s role specificpart. Since the failure may also undermine thecenter’s ability to successfully do her task, she
indeed may have special motivation to complain.
She might also feel slighted and insulted if anotherplayer routinely ignores clear opportunities to passher the ball. But none of these is naturally thoughtof as a violation of her individual rights. To
conceptualize the failure in terms of rights, actuallyfundamentally mischaracterizes the activity so as tomake the individual basic, rather than the team.
Similarly, if a member of a dance troupe forgets
his part or otherwise fails to perform adequately,
there is grounds for criticism, but it is inappropriate
and out of place to apply the language of rights
violations. Here to each member has a specializedrole in a coordinated and shared activity, and thisgives rise to distinct individual responsibilities andlegitimate expectations of others. If a dancer islifted awkwardly or if a partner is out of step, thenEubios Journal of Asian and International Bioethics 16 (January 2006)
there is grounds for complaint and criticism, but thelanguage of rights would again misconstrue thecomplaint by treating a shared activity inindividualistic terms.
In coordinated, shared,
communal activities, rights talk is typically out ofplace. Success in dance and team sports depends
on a coordinated effort, and importantly individual
success is essentially dependent on the success ofthe group as a whole.
Another context where we find rules andlegitimate expectations but no rights, are inceremonies and rituals. Here too we find specificrules and distinct roles and responsibilities that giverise to legitimate expectations from others. Indeed
etiquette and protocol generally specify symbolic
ritualized actions with social meanings that convey
respect, and can result in shame, without any
thought of rights. Of course here it does makesense to say, for example, that parents have a rightto be treated with respect by their children. Yet
when children are disrespectful, it would be strange
to say that they had violated their parent’s rights.
They clearly acted wrongly, but the wrong involves
a fracture in relationships and a failure of
responsibility. So although parents have a “right”(in the sense of a legitimate expectation) to expect
better of their children, this epistemic right, thislegitimate expectation, is not based on a priorconception of individual human rights that must be
respected.
It is based instead on the basic(unchosen) relationships and responsibilities that
constitute much of human life.
Rights however have their proper place too.
If a responsibility-based ethic is embedded in a
network of interconnected relationships, andpresuppose a common commitment to a sharedends, or a shared conception of the good, it in turnwill itself be out of place in contexts that markedly
lack these characteristics.
One clear case,recognized by proponents of Confucian ethics isthat “when a community breaks down, when there
is no common goal, and when the desire forindividual advancement or other forms ofcompetition dominate, then each person will want
and need individual safeguards or rights.”(6) In
addition, within the framework of Confucian ethics,
the Natural Law conception of government
authority, explained above, implies that the Law is
to serve the good of the subjects.
Evenauthoritarian government, which is not governmentby the people, is still for the people. This constraint
on legitimate power gives rise to an institutional
requirement for a consultation system; that is some15

mechanism for the government to hear from thepeople. You cannot hear the voice of the people ifthey cannot speak freely. It should be clear that anopen and candid consultation of the people isadvanced by freedom of political speech and theright of dissent (7). Even an authoritarian systemof government that is truly dedicated to the people,
and not to the mere preservation of its own power,should accept Kant’s conservative maxim ofpolitical obligation: “criticize freely and openly, butobey promptly.”
We have also seen, however, that the strongly
paternal authoritarian ethic of classical Confucian
thought should be replaced by the more egalitarian
ethic of contemporary political philosophy. In thecontext of a more egalitarian conception of society,human rights express the equality status and dignityof all persons. These rights include:• rights to basic goods, including adequate
nutrition, clothing, shelter, and public health andbasic health care services;• basic security rights and protection fromassault and intimidation, including freedom fromarbitrary arrest and seizure as defined by the rule oflaw;• the right to education and to equal status in
the economic and civic life of one’s society;• freedom of conscience, of religion, and ofthought;• freedom of speech and expression,
including freedom of association, and assembly;• rights of political participation, including asystem of political representation (usually a system
of voting rights), the right to peacefully petition
one’s government, and the eligibility of all citizens
for public offices.
To say that these are rights is simply to say thatthese are basic goods and that society should
protect, provide, and secure for its citizens in so far
as it is able. The first three classes of basic rights
are comparatively uncontroversial. Of course, there
is indeed widespread and serious poverty anddeprivations in the world.
But it is notcontroversial that these are basic goods that society
should strive to provide for its citizens in so far as it
is able.
Freedom of conscience and expression are more
controversial, and in many cultures these rights are
subject to significant restrictions. Contemporarysocieties are characterized by deep andunresolvable disagreements about religious,
spiritual, and philosophical conceptions of thegood. These disagreements are rooted in the fact

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Eubios Journal of Asian and International Bioethics 16 (January 2006)

that modern nations are composed of many
minority communities. It is also rooted in the
disagreements that are the inevitable result ofeducation and the irrepressible human quality offree thought and reflection. Respect for the equal
status and dignity of persons requires that we
recognize that reasonable people can disagree on
these fundamental issues of conscience. There
should be no coercion in matters of religion.
Freedom of thought and liberty of conscience thus
show respect for the reasonable disagreements thatare characteristic of modern pluralistic societies.
The extent and nature of the rights of politicalparticipation are even more complex in their
specification. John Rawls has argued that non
democratic states must at a minimum have a“consultation hierarchy” that provides a reasonablemeans for the subjects to express their interests tothe state (8). Even a hierarchical paternalistic state,
if it is to truly serve the interest of its people, musthave a system for hearing the voice of the people.
We cannot here work out the difficult details
involved in resolving conflicting rights claims andthe full specification of these rights. These details
are important matters of concrete political theory,
but the basic idea is to respect the equal status anddignity of persons as subjects of political authority.
These rights also make explicit that politicalauthority must aim at the common good of thepeople.
4. Confucian Opposition to Human Rights
Let us now turn now to contemporary Confucian
opposition to human rights. Sakamoto, Tao, Hui,and Fan have argued forcefully against “Western”
conceptions of human rights (9). “Rights pollution”
they argue has soiled the moral landscape andundermines human relationships. Although theConfucian emphasis on relationships andresponsibilities is central to a proper understandingof morality, rights also have their proper place,especially when individual interests come apart orwhen power needs restraint. By considering andresponding to their objections to rights theory, we
shall see more clearly the proper balance of rights
and responsibilities.
First objection: Tao and Fan claim that “thelanguage of rights cannot provide the resources forbuilding mutual concern and cooperative
relationships between opposing parties in asituation of competing interests … What becomes
clear is that the language of rights and the legal
system based on it tend often to exaggerate rather

than reduce the division between different parties
involved” (Fan 58-59; Tao 15).
Response: We have seen that individual rights
are appropriate in contexts where there is not ashared end between parties. A respect for rights
reflects an acceptance of the equal status of all theparticipants. A system of rights provides a social
guarantee protecting the interest of each person.
Rights thus do provide a shared starting point, abackground of agreement and mutual respect, in acontext where there is not a shared conception of
the good. Rights also provide clear procedural andsubstantive constraints on outcomes, and thus theyclearly do provide the resources for resolving
conflict when there is not an antecedent basis ofmutual concern or agreement on outcomes.
Of course, asserting one’s rights can be indeed
emphasize the divisions within society and thus besocially disruptive. Indeed that is often the point ofasserting one’s rights. The appeal to rights is mostcommon and most appropriate when pushing theclaims of the oppressed, and of disenfranchised
groups, who are resisting institutionalized injustice:women’s rights, the rights of workers, the rights of
the Dalits (untouchables), equal rights for
oppressed racial or ethnic groups, these are all
disruptive of “social harmonies” that are built on
systems of inequality. When rights are used toundermine inequality and oppression, they areindeed viewed by the powerful as disruptive. So asa progressive tool, they do emphasize the division
between the parties that has been previously
masked and hidden by a false ideology of naturaldifferences that supported the previously unequal
but harmonious social roles. It is a mistake,however, to argue that rights undermine
cooperative relationships.
Rights undermine
relationships of oppression and thereby set out the
ground rules for truly cooperative relationships of
mutual concern and mutual respect.
Second Objection: Tao and Fan argue that “theprimacy of rights tends to obscure the appropriate
relation between individuals and society. It tends
to overemphasize concerns with individual liberty
and self interest, seeing the self as essentiallyseparate from others” (Fan 59; Tao 16)
Response: Even if Confucian models areappropriate for teams, dance troupes, and the loving
relationship of parents and children, thepaternalistic, communalistic model is especiallyinappropriate for the relationship between
bureaucratic officials and citizens.
Indeed,individual rights are especially important inEubios Journal of Asian and International Bioethics 16 (January 2006)
securing cultural and religious identities in thecontext of pluralistic societies.
Freedom of
conscience, religious freedom, and freedom of
association actually secure and protect one’s social
identity from State tyranny and oppression. Rarely
are individuals targeted for repression except inassociation with a group with which they identify.
Freedom of conscience protects minority and grouprights; but it does so through the protection of theparticular individuals who collectively constitutethe social groups. The primacy of the individual is
only truly central in the individual’s right toendorse or reject a social, group, or religious
identity. The right of exit is really the only rightthat puts the individuals prior to their social
identity. Rights theory does emphasize that mature
persons have a fundamental right of individualautonomy and self determination, and thus a rightto escape from identities that they find oppressive
or inauthentic.
Third Objection: Tao and Fan argue that “amajor difficulty of such an emphasis [on individualautonomy and self-determination] lies in its
underlying notion that individuals can be abstracted
from relationships, social contexts, and evenqualities of human agency that are vital to human
life, namely the capacity and need forconnectedness, relationships and mutual care. It
tends to reinforce separation and isolation,
marginalizing family involvement and sharedfamily determination.” (Fan 59; Tao 19)
Response: This recurrent theme is puzzling.
There is nothing in rights theory that denies orminimizes the importance of community,
connectedness, and relationships. The right ofautonomy actually emphasizes the centrality of theneed for connectedness by freeing individuals from
relationships that are oppressive and exploitive.
Such relationships do not reflect a shared andmutual interdependence based on mutual care.
Furthermore, in so far as rights theory encourages
mutual respect and not simply mutual care; it
redefines, rather than denies, the importance ofrelationships and community. It is in large part
because our identities are largely constituted by oursocial relationships that inequality and oppression
are internalized in psychologically debilitatingways. The background of individual and grouprights (including the right to education and rights ofaccess to the civil society) in fact functions toundermine systematic inequality and social
oppression. Civil rights clearly express that all
subjects are equal citizens in our society and this is17

a mark of inclusion and connection. It is theviolation of rights that reinforces separation andisolation. The right of self determination is a rightto endorse or reject social identities, and as such it
in no ways denies or diminishes the importance of
one’s social identity.
As mentioned above, human rights protect
communal groups, including religious groups andethnic minorities. They also reinforce the right toform economic and social associations, like guilds,
labor unions, farmers’ cooperatives, which act for ashared set of ends or goals. Human rights provide
the essential social guarantees that lead to a vibrantcivil society of distinct social groups. Indeed, here
we see that background rights enable the formationof communities that truly reflect shared goals, andthus they do contribute to the building ofcooperative relationships and that they are often
based on the essentially connected nature of humanbeings. This is why John Rawls defends his idealof social justice as embodying the ideal of a “social
union of social unions.” Modern states are made upof many communities and associations.
The
challenge is thus to describe a basic structure ofsocial, economic, and political institutions that
embody fair terms of social cooperation between
groups that do not all share a common way of lifeand conception of the good. The principles ofjustice, if they are to win the allegiance of all, must
provide a framework for a “social union” of groups
that do not share the same ethnic and cultural
identity, religious beliefs, philosophical worldview,or class identity. All of these smaller social unions
must be brought together into a larger shared social
union. Since this larger union cannot simply
assume a common identity, set of ends, orconception of the good, it must provide social
guarantees for the basic rights of its members. It isonly the background of civil, economic, andpolitical rights that provides the framework fortrust, a shared sense of social justice, and a national
identity to take root and grow.
In response to western communitarian critics,
pressing the same objections as the Confucian
critics, Rawls has emphasized that his liberalegalitarian theory of justice is a “political ideal”
and not a comprehensive moral outlook. It is toprovide a shared basis for political life for disparate
communities (and thus individuals) with distinct
comprehensive conceptions of the good. The social
circumstances of justice in modern pluralistic
societies involve deep and irreconcilable
differences in comprehensive religious and moral

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Eubios Journal of Asian and International Bioethics 16 (January 2006)

outlooks, and thus the goal is to construct a sharedcivil life that takes seriously these differences.
Despite deep and unresolvable differences withother groups of people, we share with them the goalof living together in peace and mutual respect. It is
this shared commitment by people with otherwise
diverse conceptions of the good that is the basis offundamental rights and liberties, including libertyof conscience, political rights, and of the basic
rights of persons to security and welfare (10).
Fourth Objection: Hui, Sakamoto, and Fan havesuggested that “the rights-based notion of
personhood is developed from the long-standing
Western view of substance. A human person is
primarily a rational individual substance. This
assumption of rational substance contributed tocontemporary bioethics the narrow psychologicaland individualistic understanding of personhoodand the rights-based ethic.” (Fan 59; Hui 31;
Sakamoto 46)
Response: This objection is more abstract inthat it claims that the difference between Confucian
relational ethics and individualistic rights theory isfound in philosophical metaphysics. In order toavoid a lengthy excursion into metaphysics, we willaddress this objection only briefly. It should beenough to note that we have already seen that anemphasis on individual rights need not include aradical (or methodological) individualism, and thatit need not deny the centrality to our identity ofcommunity or relationships. We have also seen, inthe previous section, that Western moral
psychology also emphasizes the centrality of ourprimary family relationships to our moral (andintellectual) development. These points alone
suggest that a concern for basic human rights is notbased on a radical individualism that is rooted inmetaphysics of substance.
On the other hand for those readers interested ina more direct response to this objection: The
substance view (however this is understood) isneither necessary nor sufficient for a rights based
ethic. It is not sufficient because it was Aristotle’sview, and he famously developed a naturalistic
teleological virtue ethic (with well known
similarities to Confucian ethics). It is also not
sufficient because, as the argument alleges the“Western view of substance” was a common viewin the West for a thousand years before the rights
view emerged in the West. More importantly, there
is no clear shared Western view of substance. (It is
not as if Heraclites, Parmenides, Plato, Aristotle,
Descartes, Leibniz, Locke, Hume, Kant, Nietzsche,and Mill all shared the same metaphysics ofsubstance and conception of the self.) In addition,
the two most important western philosophers formodern moral and political theory are Kant andMill, and both reject the metaphysical idea ofrational substance. It thus seems that this view ofsubstance is not a necessary condition for a rightsbased ethic. Finally, the true paradigm case of amethodological individualism and rational egoism,
the only figure to truly subordinate even the family
to the sovereignty of the individual, is Thomas
Hobbes. Yet Hobbes completely rejected the ideaof a person as a rational substance, and thoroughly
rejected the idea of human dignity as the basis ofrights. Of course, ironically, Hobbes was thegreatest competitive individualist and also thestrongest defender of social order and paternalistic
sovereign authority (11). We conclude that there isno simple relationship between the metaphysics ofthe person, especially the metaphysic of rational
substance, and individualist liberal rights theory.
We have seen that there is no fundamental or
deep opposition between the Confucian naturalistic,
relationship-centered, ethic and contemporary
rights theory. The points of opposition are over thejustification of paternalistic and authoritarianconceptions of society, and over the idealization ofhierarchical relationships in general. We havesuggested instead that a more egalitarian Confucian
ethic, modeled on the relationship of friendship,provides the more apt ideal of human relationships.
On the other hand, Western rights theorists are wellserved by recognizing the primacy of relationships
and also the importance of the family to thepsychology of moral development. Relationships
are at the heart of our moral life, and they are
constituted by a focus on responsibilities not rights.
Basic human rights, however, provide thebackground conditions limiting and defining thenature of basic social relationships and social roles
so that embody mutual respect and reciprocal
benefit. Rights talk also expresses a shared end, ashared commitment to oppose socially reinforced
inequality and oppression. Rights define the basic
shape of social unions, and also the larger politicalassociation that is a “social union of social unions,”
but in a just society relationships are indeed thesource of the responsibilities that constitute thebulk of our moral lives.
5. The Patient-Physician Relationship
East Asian medical ethics, with its foundations
in Confucian Ethics, is family-centered and tends toEubios Journal of Asian and International Bioethics 16 (January 2006)
be paternalistic. As a result, it is claimed, Asianmodels of the patient-physician relationshipconflict with the Western autonomy-centeredmodel of informed consent. There are two issues
here: one is medical paternalism and the other is therole of family. First paternalism: it is noteworthy
that the arguments for medical paternalism are nodifferent from the arguments for paternalism that,
until quite recently - as recently as 1970, were
widely accepted in the West too. The difference
here is more one of a substantive disagreement thana cultural difference. For example, whether or not
the disclosure of a diagnosis of cancer is directly
harmful to the prognosis of the patient and thus
contrary to medical benevolence is a substantive
matter. Many factors and reasons contributed tothe move away from the paternalistic approach to
medicine. Some of the more important reasons
were (i) the need for informed consent for cancer
research on human subjects, (ii) the improved
prognosis for the successful treatment of cancer,(iii) a better understanding of the dying process,and (iv) the empirical evidence that disclosure does
not affect morbidity and mortality outcomes. In
light of these factors (and others) the argument,from patient-harm for paternalistic non-disclosure,
simply was not sustainable.
However, even with the recognition of anindividual right to informed consent (and thus
disclosure), the physician-patient relationship is notbest understood on a narrow rights-based,autonomy model. We have seen that even whenrights provide background conditions specifying
the basic conditions of a relationship, a focus onrights often mischaracterizes the cooperative natureof the relationship. Patient and physician share acommon goal:
maintaining or restoring thepatient’s health, if possible, and, when the patientcannot be cured, the relief of suffering and a good
death. In addition to a shared goal, like otherrelationships, the patient-physician relationship is
one of distinct roles and responsibilities. The
physicians bring to the relationship medical
expertise and much experience with disease,healing, and death. The patients bring a personalawareness of their symptoms, important
information about their past, their medical andfamily history, their personal habits, and of course
their values and preferences.
The patient depends on the physician as a
medical expert, an authority, and this requires bothknowledge (including continuing education) andthe virtue of discernment in daily practice. In

19

Asian bioethics, the art of medicine is often
referred to as the “art of compassion.”
Compassion and care for patients is the core virtueof medicine.
Patients, however, must trust
physicians with their lives, and with deeply
personal information. We expose ourselves to ourphysicians like no other person, and we do so
because we trust them to respect our privacy byhonoring the principle of confidentiality. To
maintain this trust, physician must scrupulously andconscientiously maintain their professional
integrity. Most obviously, physicians should avoid
conflicts of interest based either in economic
incentives or professional ambitions. Knowledge
and Discernment, Compassion, Trustworthiness,
and Integrity are the core virtues of physicians,
which we simply take for granted when we handourselves into their care (12).
Patients also must be honest with their
physicians. It is imperative to fully disclose
everything that may be relevant to one’s condition.
It is for the physician, and not the patient, to decide
what is and what is not relevant, and thus allquestions should be answered as fully as possible.
The second responsibility of patients is compliancewith the course of treatment. Physicians cannot
help patients if patients are not willing to help
themselves. Non-compliance of course hurts thepatient most, but it also wastes precious medical
resources, including the time of physicians that
could have spent caring for others. The patient
should conscientiously follow the treatment
decision, but the patient’s preferences and values
must also shape the treatment recommendation.
Assuming that we have a competent patient, the“deliberative model” of the patient-physician
relationship is clearly the most appropriate (13).
This is a model of shared decision making, which isincreasingly popular with medical ethicists. Most
models of shared medical decision making
emphasize the “fact-value division of labor between
the physician and patient.” We turn to physicians
for medical advice, and it is thus obvious that thephysician is the source of medical information – thefacts. But it is the patient’s own values that must
direct and determine the decision about the courseof treatment. There is clearly something to thisidea for it is the distinct values and principles that
undermine the objectivity of medical decision
making. Still this division between facts and values
is really quite artificial. First, if one has turned to
medical expertise, it is clear that the value of healthand avoiding suffering are obviously shared values.

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Eubios Journal of Asian and International Bioethics 16 (January 2006)

Inpractice,doctors
routinely
makerecommendations based on straight-forward
consideration about medical outcomes and theobvious goal of not being sick (or avoiding
suffering). It is only in the more difficult cases,
with differential treatment options each with
distinct risks of side-effects, that more subtle value
considerations are necessary.
Second, ideallyphysicians do know their patients basic values, andthus they can still make recommendations that are
most likely to reflect their particular values.
Physicians do not, and should not, just give medical
facts and let patients decide. They make specificrecommendations and patients would be surprised
if they did not. Third, physicians should help guidepatients in thinking through the medical options
and thereby form their distinctly medical values. It
is not as if we come to a serious medical decision
with clear pre-formed preferences about medical
outcomes and risks. We don’t know what it is liketo endure various types of available treatments, wedon’t know how to weigh the risks, and we don’tknow how we will react to various forms oftreatment and disability. Furthermore, it is acommonplace that how alternatives are presented(framing) shapes judgments of risk and benefit; thateven competent people have irrational fears ofsurgery and post surgical pain. In general, people
are poor predictors of what will make them happyor cause suffering. Especially in novel situations,
we are not good judges of how we will respond tothings that we think we want or even that we aresure that we could not bear. Physicians will
inevitably frame choices in ways that they believe
are in the best interest of patients. Nothing is
gained by denying this, and it is in fact much betterto face these obvious facts head on. Of course,
physician should not force patients to endure
treatments that they steadfastly reject. When the
deliberation has come to an end, they ought to deferto the patient’s judgment. But doctors will, andthey should, share the wisdom of their experience -especially when it involves their judgments of ourbest interests. What they should conscientiously
avoid is imposing their own preferences, andespecially their moral or religious values on to theirpatients. Although this is sometime a fine anddifficult line to draw, it is the ideal and it is indeed
involves nothing less than the art of compassion.
The ideology of autonomy, understood as radical
individualism and independent self-determination is
unrealistic, and it does not reflect medical practicein the East or West.
The ideology of theauthoritarian paternalistic physician dispensing
medical orders to passive and uninformed patients
is equally misguided. The medical relationshipshould reflect the nature of the relationship itself
and to do so is to recognize and embrace adeliberative model of shared decision making.
Patients should respect physician medical authority
and experience. Physicians should be responsive tothe values of the individual patient, but should also
help them choose sensibly when faced with noveland difficult decisions of life, death, and disability.
Respect for autonomy does not mean simply
deferring to superficial initial preference.
Ifautonomy is worthy of respect it requires at least arational, informed and reasoned, self-determination.
When facing illness, disability, and mortality, apatient may needs a caring physician to guide themthrough. The ideal physician does much more thanprovide the medical facts and leave the decision to
be made by a scared and vulnerable patient.
The second element of Confucian bioethics is its
family-centered conception of informed consent.
One of the problems with Western medical ethics isthe absence of the family from the center of the
discussion. We have the individual patient, thephysician, and society as the prime players. In
reality, we have the patient and family, thephysician and medical team, and an extending webof social relations that includes day to day
associates, the insurance pool and distant strangers.
The individualized model of physician and patient
bears little resemblance to the medical reality with
its interdependent and interconnected web ofrelationships. The Confucian relational model
more accurately reflects the complex social
dynamic of medical ethics. On the medical teamside we have the attending physician, nursing staff,
consulting
physicians,
medicalspecialists,
psychiatric consultants, social workers, staff clergy,
risk management staff, and perhaps medical ethics.
On the patient side we have, most importantly, thecentral role of the family in medical decisionmaking. In theory, the role of the family is mostclear in surrogate decision making for incompetentpatients. In practice, the family is always part ofthe daily dynamic of medical practice. If a family
member is at hand, they are inevitably and naturallypart of the medical discussion and decision making.
We have husbands and wives and domestic
partners, the parents of an adult son or daughter, theadult son or daughter of a parent, as well as
siblings, cousins, and even close friends, filling thewaiting rooms and sitting with patients.

Eubios Journal of Asian and International Bioethics 16 (January 2006)
The real difference is that in countries like China
this reality is more clearly acknowledged, and more
importantly the families themselves are moreclearly structured and defined. It is common in
China, for example, to inform the family of thepatient’s condition prior to informing the patient.
The family will then inform the patient, ideallywith the physician standing by to answer question
or clarify any misunderstanding. How and when
information is disclosed, and how much bad news
is disclosed, is left to the discretion of the family,
not the physician.
The physician may discussdifficult medical decisions with the family rather
than the patient. Patients, however, are aware ofthese practices and tacitly consent to them. Indeed,in the case of a close family it clearly would be
disruptive to treat the family as if they were mere
outsiders. In the West too we adjust and respond tothe clear expectations of patients. A husband or
wife is fully included in medical discussions withpatients, and is often informed first of the patients
condition. This is taken for granted and not evenmuch noticed. The difference is not one of basic
principle. It is simply a matter of different family
structures and differential patient expectations.
Given the cultural expectations, we would not havea disagreement of principle unless the patient
objected to the common practice and requested
privacy or confidentiality. The autonomy model of
informed consent can fully accommodate a familycentered culture, as long as the individual family
members accept their particular roles in the family.
Some might object that given the cultural
expectations, there is no real opportunity to dissent
and thus there is not really meaningful tacit
consent. Whether patients truly accept, rather thansimply, acquiesce in their family roles is hard toknow. But this is equally true of family dynamics
everywhere. The more important question iswhether the dynamic of family-based decisionmaking indeed helps the patient who is facing
serious illness and perhaps death.
Informed
consent is supposed to protect the interests andvalues of patients. As long as family-based
medical decision-making respects the patient’s
interests and deeper values, it is indeed only a
misguided individualism that would reject the aid
and comfort of loved ones.

21

References
1) For a basic introduction to Confucian thought, see Jennifer
Oldstone- Moore, Confucianism (Oxford, 2002). Also see A
Source Book in Chinese Philosophy translated and compiled
by Wing-Tsit Chan (Princeton, 1963)
2) See Norman Kutcher “The Fifth Relationship: Dangerous
Friendships in the Confucian Context.” The American
Historical Review 105.5 (2000); August 9 2005.
http://www.historycooperative.org/journals/ahr/105.5/ah001
615.html
3) Ruiping Fan “Rights or Virtues? Towards a
Reconstructionist Confucian Bioethics,” p. 61, in Bioethics:
Asian Perspectives, edited by Ren-Zong Qui (Kluwer,2004).
4) The discussion that follows is based on John Rawls’
account of moral psychology in part III of A Theory ofJustice (Harvard, 1973). Rawls’ account is based on
Lawrence Kohlberg’s stages of moral development.
5) Craig Ihara, “Are Individual Rights Necessary?” inConfucian Ethics, ed. Shun & Wong (Cambridge, 2004).
6) Ihara p. 27.
7) For a discussion of freedom of expression in Confucian
ethics, see David Wong, “Rights and Community inConfucianism” in Confucian Ethics, ed. Shun & Wong
(Cambridge, 2004)
8) See John Rawls, The Law of Peoples (Harvard, 1991).
9) Sakamoto, “The Foundations of a Possible Asian
Bioethics,” Tao, “Confucian and Western Notions of
Human Nature and Agency,” Hui, “Personhood andBioethics: Chinese Perspectives,” and Fan “Rights or
Virtues? Towards a Reconstructionist Confucian Bioethics,”
in Bioethics: Asian Perspectives, edited by Ren-Zong Qui(Kluwer, 2004).
10) Here we also need to avoid a very basic confusion about
the motivational postulates defining Rawls famous
hypothetical contract device, the Original Position, as
opposed to the moral psychology of citizens of a wellordered society. Contrary to the claim of Fan, and others,
Rawls has never argued that actual people or ideal citizens
are “mutually disinterested” (Fan 64). The Original Positionis simply a hypothetical choice situation, an imaginary
device, and it is not an idealization of human nature. Rawls
also stipulates that we set aside all knowledge of ourconception of the good, status in society, age, and naturalabilities under a “veil of ignorance.” It is surely clear thatRawls is not suggesting that people do not know thesethings. So too he is not suggesting that people are or evenshould be mutually disinterested.
11) Hobbes argument here mirrors the argument of Hsun
Tzu, and his account of how ethics (the rites) must
transform the original fundamentally “evil” human nature.
See A Source Book in Chinese Philosophy translated andcompiled by Wing-Tsit Chan (Princeton, 1963).
12) See, for example, Beauchamp and Childress, Principles ofBiomedical Ethics, 4th edition (Oxford, 1994); chapter 8 on
“Virtues and Ideals in Professional Life.”13) Ezekiel J. and Linda L Emanuel, “Four Models of the
Physician Patient Relationship” in the Journal of theAmerican Medical Association 267, no 16, April 1992:
2221-26.

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Eubios Journal of Asian and International Bioethics 16 (January 2006)

Black identity and registries in
Brazil: a question of rights andjustice- Eliane S. Azevêdo, MD, PhD
Department of Biology, Nucleus of Bioethics –UEFS, 44031.460 Feira de Santana, Bahia, Brazil
E-mail: eedsea@uol.com.br- José Tavares-Neto, MD, PhD
Faculty of Medicine, Nucleus of Bioethics - UFBA
40026-010 Salvador, Bahia, Brazil
E-mail: tavares-neto@uol.com.br
Brazil has a unique human genetic history.
Initially, only native Indians inhabited the land. At
the beginning of the XVI century, the native
population was estimated in two million souls. The
first Blacks arrived around the year 1520, at thesame time of the arrival of larger groups of White
explorers. An extraordinary process of racialintercrosses occurred among native Indians, Black
Africans and European Whites, mostly Portuguese.
Two and half centuries later the population ofBrazil was described as being made up of 20%
Mulattoes (persons of mixed ancestry). The first
demographic census, dated 1872, pointed that 32%of the slaves and 78% of the free Blacks wereMulattoes [1, 2].
The main point is: for some cultural reasons, theBrazilians always considered the Mulattoes as agroup, neither Black nor White. On the other hand,
the North American did the opposite: the smallest
evident of Black ancestries would let the person to
be seen as Black. Not only that, but the use of terms
such as Mulatto, miscigenated or mixed, becamesocially unaccepted among the north-Americans
people, but not in Brazil. Thus, since theseventeenth century the Brazilians see themselves
as Black, Mulatto or White. After many generationsof racial intercrosses the present estimates are that
we are reaching total panmixia. So, even thosemore Black carries about 18% of genes from White
ancestries, as those more Whites has about 7% ofgenes from the Blacks [3, 4, 5].
The Brazilian cultural identity is essentiallymixed. We are mixed not only in our genetics
heritage but also in our souls: we are mostly Roman
Catholic but we also praise our syncretism mixing
religious traditions and faith from Black Africans,White Portuguese and native Indians. Theintercrosses among Blacks, Whites and Indians are
deeply craved in our cultural roots as well as in our

genetic make up. There is no way to dismiss our
three ethnic heritages either in healthy or indiseases situations.
Recently, the Black-descendents in Brazil
achieved some steps ahead on their social
conquests. The public Universities created a new
system of admission aiming to desblock the accessof poor Black students to university courses. The
prevailing poverty among the Black descendents
always impaired them to afford privates schools,
making the competitive access to the University
nearly impossible. Now, the new system reserves
some percentage of the university vacancies forstudents having both; Black ancestries and basic
education in public schools. Thus, presently, theself-identification of Black ancestries is, in many
public institutions, a requirement to compete to
public University vacancies in Brazil.
Also, recently, in Brazil, the Ministry of Healthand the National Research Council are investing
special budget to foment research on special healthproblems of the Blacks. Consequently, the researchon this subject has improved in number and quality
which may well give a good return in health public
measures to benefit the health quality of the Blacks
ancestries Brazilians.
Poverty, Black ancestries and healthAs seen, our social history can not be praised as
our genetic heritage. If, special measures areneeded to be taken by the Brazilian Government, inthe beginning of the 21st century, to improve thehigher education and health of the Blacks, isbecause they had been neglected for five centuries.
Unfortunately, the dreadful injustices of slavery
remain present in Brazilian society allowing allkind of social blockages for Blacks. The prejudicein Brazil is dismissed, but effective, in spite thehigh levels of intercrosses. An example of prejudicecomes from a brief inquiry made by our nursing
students in Bahia State, at one of our public
hospital. The results of the interview showed thatall doctors admitted that, in their own practice, they
make no difference in the quality of attention given
to Black patients. However, 100% of them assured
that their colleagues do act differently if the patientis Black.
As was seen, our social heritage is maculated by
the slavery of Blacks, exploitation of the Native
Indians and unlimited domination of the Whites.
Presently, we share genes from Black Africans,
Native Indians and European Whites but we do notshare properties, richness, welfare, education,

Eubios Journal of Asian and International Bioethics 16 (January 2006)
health care and many other goods of life. Social
inequality linked to ethnic ancestrality became ourmark. Those having more Black ancestries remain
being the poorest, having the fewest opportunities
for social improvement, education and health care
[6, 7].
Studies carried out by the Research Institute ofApplied Economics (IPEA),a Brazilian
governmental institution, showed, based on census
data, that Whites and Blacks descendents live inentirely different realities [8, 9]. In spite of somegovernmental efforts inspired on the International
Work Organization (1968), the improvement ofBlack person’s social conditions had been below
expectations and unable to break down the existing
apartheid [9].
In 2001, Henriques [8] showed that, in theoverall, 45% of the Brazilians are afro-descendents,
but 68.8% of the indigent and 63.6% of the poor,
are Blacks. In addition, on the two tails of thewealth distribution, among the richest 10%, only
15% are Blacks, but among the poorest 10%, 70%
are Blacks. Henriques [8] extends his studies
showing that between Blacks and Whites thedissimilarities are also on education levels, housing,health care and income.
If the official data on these various types ofregistries did not informed the ethnic groups of thepersons, there will be no way to show this shamed
reality. In the case of medical records, for example,
in the absence of racial registries there will be nomeans to observe and denounce that Black women
have greater risk of maternal death than Whites[10]. Not only that, but in the city Rio de Janeiro, a
study on normal delivery conditions disclosed thatthe frequency of anesthesia applications is higher
for White females (11.1%) than for Blacks (5.1%)[10].
Thus, facing such inhumane tragedy, some
Brazilians still nourish the illusion that, by omitting
the registry of Black ancestries, either on official
census, documents or medical records, they will
impair prejudices and improve social opportunities
and medical assistance. The problem is not on theregistry itself but on the register’s minds. The
registry we need to erase is not in the records but inpeople’s heart. Blacks have their own ethnic
identity which must be registered, preserved andrespected [11].
The importance of ethnic identity in the medical
records has not only medical importance but also
ethical value. If there is any concern that the ethnic
registry would mislead a diagnose, the same kind of23

concern would holds true for sex and age registries.
The medical doctors must have open minds, notmyopia, regarding biological characteristics anddiseases. The interrelationship between nature andnurture in medicine must be viewed from bothsides: susceptibility and resistance. In respect toBlack ancestries and medicine, Brazil, for its
unique genetics history, is full of good lessons. Let
us take the example of schistosomiasis.
As reported by Silva in 1908 [12], infections
with Schistosoma mansoni has been documented in
Brazil since the beginning of the 20th century. The
various clinical manifestations of the disease havebeen well characterized by many Brazilians´investigators [13, 14, 15]. Until the middle of the20th century it was generally believed that theseverity of the disease was solely related to theintensity of the parasitic infection. In 1953,
Cardoso [16] called the attention to the fact that theBlacks did not have the severe form ofschistosomiasis in spite of their poverty. In the
1970s, various investigators came to the sameconclusion by studying groups of patients [17, 18].
In 1978, Bina et al. [19] published two studies
comparing the distribution of Blacks, Mulattoes
and Whites patients with schistosomiasis andcontrols verifying the effect of Black ancestries on
the progression of the disease. The results showedthat the Blacks have individual resistance fordeveloping severe schistosomiasis. In addition, thisresistance is observed regarding the clinicalprogression of the disease, not to the infection rateby the parasites [20]. Later, Tavares-Neto & Prata[21] and Tavares-Neto [22] confirmed theseprevious findings by showing greater frequencies ofsevere schistosomiasis among White patientscompared to the Blacks ones, plus the newobservation of better regression of the disease
among treated Mulattoes patients than among
treated Whites.
In spite of not being specific of Black
populations, the Hemoglobin S (HbS) genedeserves some comments. When in homozygosity
the Hb S gene causes sickle-cell anemia, a severe
inherited disease, but when in heterozygosity thesame gene plays a well known protection against
severe form of falciparum malaria [23]. This
protective mechanism is the best example of the
Darwiniannaturalselectioninhumans.
Consequently, the high prevalence of falciparum
malaria in equatorial Africa, protected the HbScarriers from death due to malaria thus increasing
the gene frequencies on native populations as well

24

Eubios Journal of Asian and International Bioethics 16 (January 2006)

as in their descendents [24]. This example makes
clear that, regarding gene action; there is no way toclaim a gene as bad or good. In a malaria area, it isgood to have a single dose of the Hb S gene, but at
any other place in the world it is bad to have thedouble dose of this same gene.
Other diseases had also been related to Black
ancestries regardless of geographic regions orcountries [25]. Some of these diseases, such as
Chagas´ disease in Brazil, are so deeply related topoverty that makes the association with Black
ancestries is likely social in origin than biologicallydetermined [26, 27].
Cardiac diseases related to high blood pressure
also are more frequent in the Blacks either fromdeveloped countries [28] or from undeveloped
ones. In Brazil, even among the poorest people theassociation between severe hypertension and Black
ancestries is observed [29].
Finally, in Brazil, especially in the past, theWhite explorers used racial identification tostrengthen their power and privileges, facilitating
labour exploitation [30]. In our days, however, theethnic identification of Blacks in demographic
census, public documents, medical records,
research data, etc., became of major importance toallows estimates of social inequalities, to declaresuch injustices, and to force public measures
towards the construction of social justice for every
Brazilian.
References
1.
Bergman, M. (1976). Nasce um povo. Vozes:
Petrópolis, Rio de Janeiro.
2.
Roquete-Pinto, E. (1933). Ensaios de Antropologia
Brasileira. Comp. Ed. Nacional: São Paulo.
3.
Azevêdo, ES. (1980a). Subgroups studies of Black
admixture within a mixed population of Bahia, Brazil. Ann.
Hum. Genet (Lond) 44: 55-60.
4.
Azevêdo, ES. (1980b). The anthropological andcultural meaning of family names in Bahia, Brazil. Curr.
Anthropol 21: 360-363.
5.
Krieger, H.; Morton, N.E.; MI, M.O.; Azevêdo, E.S.;
Freire-Maia, A.; Yasuda, N. (1965). Racial admixture in
north-eastern Brazil. Ann. Hum. Genet. (Lond) 29: 113 -125.
6.
Souza, M.G.F.; Azevêdo, E.S.; Silva, M.C.B.O.; Freire,
N.B.V.M. (1987). Brancos descendentes de negros nasociedade brasileira. Ciên. Cult. (São Paulo) 39: 1186-1189.
7.
Dias, L.R. (2004). Quantos passos já foram dados? Aquestão de raça nas leis educacionais. Da LDB de 1961 a
Lei 10.639. Revista Espaço Acadêmico, n. 38, 8p.
Disponívelem<http://www.espacoacademico.com.br/038/38cdias.htm>.
Acesso em 19 de janeiro de 2006.
8.
Henriques, R. (2001). Desigualdade racial no Brasil:
evolução das condições de vida na década de 90. Instituto
de Pesquisa Econômica Aplicada (IPEA): Brasília, 52p.

9.
Jaccoud, L.; Beghin, N. (2002). Desigualdades raciais
no Brasil: um balanço da intervenção governamental.
Instituto de Pesquisa Econômica Aplicada (IPEA): Brasília,152p.
10. Martins, A. L. (2004). Diferenciais raciais nos perfis e
indicadores da mortalidade materna para o Brasil. In: XIV
Encontro Nacional de Estudos da População da Associação
Brasileira de Estudos Populacionais (ABEP), Caxambu(MG, Brasil), 23p.
11. Azevêdo, E. S. (1980). Raça: Conceito e Preconceito.
Ática: São Paulo, 62p.
12. Silva, P. (1908). Contribuição para o estudo da
Schistosomíase na Bahia, Brasil. Brasil Méd. 22: 281-283.
13. Prata A.; Bina, J. C. (1968). Development of thehepatosplenic form of schistosomiasis. Gaz. Méd. Bahia. 68:
49-60.
14. Neves, J. (1970). Quadro Clínico. In: Esquistossomose
mansoni. SARVIER/USP: São Paulo.
15. Coutinho, A. (1973). Fígado e esquistossomose. J.
Bras. Med. 25: 23-42.
16. Cardoso, W. (1953). A esquistossomose mansônica no
Negro. Med. Cir. Farm. 202: 89-93.
17. Prata A.; Schroeder, S. (1967). A comparison of Whites
and Negroes infected with Schistosoma mansoni in a
hyperendemic area. Gaz. méd. Bahia. 67: 93-98.
18. Nunesmaia, G.N.; Azevêdo, E.S.; Arandas, E.A.;
Widmer,C.G.
(1975).
Composição
raciale
anaptoglobinemia em portadores de esquistossomosemansônica forma hepatoesplênica. Rev. Inst. Méd. Trop. São
Paulo 17: 160-163.
19. Bina J.C.; Tavares-Neto, J.; Prata, A.; Azevedo, E.S.
(1978). Greater resistance to development of severe
schistosomiasis. Human Biology 50: 41-49.
20. Tavares-Neto, J.; Santos, S.B.; Prata, A. (1991).
Esquistossomose-infecção e raça dos portadores. Rev.
Latinoam. Microbiol. 33:49-54.
21. Tavares-Neto, J.; Prata, A. (1988). Regressão da forma
hepatosplênica da esquistossomose, após tratamento
específico, associada á raça. Rev. Soc. Bras. Med. Trop. 21:
131-133.
22. Tavares-Neto, J. (1997). Marcadores sorológicos das
hepatites B e C em residentes de área endêmica daesquistossomose mansônica.
Tese de Livre-docência,
Universidade Federal da Bahia, Salvador, BA, Brasil.
23. Allison, A. C. (1954). Protection afforded by sickle-celltrait against subtertian malaria infection. Brit. Med. J. 7:
290-292.
24. Allison, A. C. (1964). Polymorphism and natural
selection in human population. Cold Spring Harb. Symp.
Quant. Biol. 29: 137-149.
25. Cruichshank, J. K.; Beevers, D. G. (1989). Ethnic
Factors in Health and Disease. Butterworth & Co.
(Publishers) Ltd. London, England. 324p.
26. Azevêdo, E.S.; Tavares-Neto, J.; Carvalho, R.E.;
Alves, M.G.H. (1979). Further studies on the association of
Chagas disease and race. Ciênc. Cult. (São Paulo) 31: 671675.
27. Marsden, P.D.; Virgens, D.; Magalhães, I.; TavaresNeto, J.; Ferreira, R; et al. (1982). Ecologia doméstica do
Triatoma infestans em Mambaí, Goiás – Brasil. Rev. Inst.
Med. Trop. São Paulo 24: 364-373.
28. Cooper, R.S.; Rotimi, C.R.; Ward, R. (1999). The
puzzle of hypertension in African-americans. Sci. Am. 280:
56-63.

Eubios Journal of Asian and International Bioethics 16 (January 2006)
29. Noblat, A.C.B. (2004). Influência da raça, gênero eidade nas complicações da hipertensão arterial em
pacientes atendidos em serviço de referência da cidade deSalvador, Bahia. Tese de Doutorado, Faculdade de
Medicina da Bahia da Universidade Federal da Bahia.
30. American Anthropological Association. (1998).

Population genetics and thepower of discrimination- Luzitano Brandão Ferreira(Programa de Pós-Graduação, Universidade de são Paulo)

Av. Caramuru 2.200 Apto 102
Ribeirão Preto-SP, CEP 14030-000, Brasil
Email: luzitano@directnet.com.br
Human diversity is well evident and the attempts
to describe it have been the objective of research ofdifferent areas of knowledge. One of these areas ispopulation genetics. It can be described as the studyof the distribution of the allele (any one of thedifferent forms of the same gene) frequencies in a
population. The verification of the variations in
populations can relate to discrimination.
Since the decade of the 1950s there is thepossibility to detect different shapes of a same
protein. Since 1980, with the development of moresophisticated techniques capable of studying genes,
it was verified that diversity is much higher thanthat observed by the proteins or described byexternal morphological criteria. The ever increasing
ability of researchers to examine larger numbers ofgenetic variations in humans and to draw
conclusions of anthropological, historical andmedical interest with them, has increased publicknowledge of this kind of research, and also raised
new ethical problems.1
The majority of the alleles are present in thegreat part of the population, but in varied
frequencies.2 Even though the differences observed
among populations are more quantitative thanqualitative, because of the common origin and shortdivergence time among human groups, there aredifferences in the frequency which some alleles arepresent in the population.
The designation of genetic variant as "private"
was first given to ten variants of proteins found in
Amerindians.3 After that, expression of a "uniqueallele" was utilized to describe the presence ofalleles in just one population.4 Nevertheless, eventhe markers formerly considered "private" or"unique", are not exclusive or restricted to only one
population. Because of that, in 1997, the25

designation "population specific alleles” was used
to describe markers with great differential
frequencies, arbitrarily defined as > 50% between
at least the greater geographical population Africans, Europeans, Asiatic and Amerindians.5
More recently, these alleles with great differential
frequency were denominated “ancestry informative
markers."
It is important to say that these markers areindicators of biogeographical ancestry and not of“human races”. From the biological point of view,the concept of race has been abandoned because it
is vague and imprecise,6 arbitrary and typological7,
it does not distinguish human populations,8 it isunable to explain the complex biological humanchanges9 and it does not represent the evolutional
history of humans.10
Even though the concept of race is equivocated,
there are little genetical variations among thehuman groups that can define the biogeographicalancestry, or the geographical origin of individuals.
Among the alterations that can help in the
differentiation of human populations are thosepresent in the mitochondrial DNA (mtDNA). This
type of DNA is present in mitochondria (organelle
responsible for the production of energy in thecell), it possesses few more than 16.500 pairs of
nucleotides and it is inherited only from women(mother inheritance).
Alterations have been accumulated in this typeof DNA through dispersion of maternal lineage in
different geographical regions,11 resulting in its
specificity in some populations.12 Therefore, thepresence of the base thymine (T) in the position
3594 of mtDNA, virtually absent in non Africans
can be considered specific from Sub-Saharian
Africa, being present in 60-100% of the individuals
from this region.13 The absence of the base adenine(A) in the position 7025 is characteristic ofEuropeans14 and the presence of the base guanine(G) in the position 663 of Amerindians andAsiatics.15 Several other alterations of mtDNA andnuclear DNA may be considered informative
markers of biogeographical ancestry.16
Several laboratories all over the world are
already capable of identifying African, Amerindian,Asiatic and European biogeographical ancestry forpeople that wish to know their genetical origin.
This separation of populations goes beyond theselarge human groups. As long as the knowledge ofthe distribution of several markers increases,
several ethnic groups can also be differentiatedwith distinct grades of specificity.

26

Eubios Journal of Asian and International Bioethics 16 (January 2006)

In spite of that, it is needed to remember thatthese markers represent a small part of all humanDNA. Because of this small difference, we see thatthe presence of a base in the position 3954 of
mitochondrial DNA, specific of Africans,represents only an alteration in the more of 3 billionof pairs of bases in the human genome.
Even though the differences among humangroups are small, they can be detected genetically.
A great problem that can resurge from thisknowledge is the belief in the existence of humanraces. Even being a old-fashioned concept, this is
not enough to abandon this classification withsevere ethical repercussions. Racism is deeply
embedded in the assumptions of biologists andsocial scientists in general17, and these ideas do notdepend on scientific fundamentals. Eugenics is agood example of how beliefs and personal desires
can be much stronger than any scientific argument
and of how the science can be used in a wrong way
to accomplish certain goals.
Another problem that can arise is genetic
discrimination. This problem is mostly connected
to diseases or predisposition to diseases. The
genetic discrimination by insurance companies andbosses is well known.18 With the development ofgenetics of populations and of new markers, thegreater vulnerability of individuals will be not only
because of the diseases, but also by the genetic
ancestrality of individuals or any other pattern that
we can imagine and reach through genetic exams.
Subjects will be discriminated not only racially, butalso from a certain country, geographical region or
ethnic group, in agreement with the grade ofrefinement that the genetic tests allow and mainlyin accordance with the interest and the criteria
utilized by who desires to do the discrimination.
The information of biogeographical ancestry
must be shown with extreme care to the populationin general and even in the scientific field. It must beemphasized that identifying individuals in specificgroups on the basis of genetic criteria is asociological process in which biology is invoked as
evidence of identity, but the prestige of scienceshould not privilege genetic studies or distract
attention away from the social mechanisms that
individuals and group form a sense of identity.19,20
It is need to remember that DNA can tell us theregion where our ancestors came from, but cannot
restore our identities, because identity it is our setof values and do not reside in the genes.21
The knowledge supplied by the genetics of
populations is useful in areas including medicine,

biology, anthropology and forensic sciences.
Studies about polymorphisms in different
populations are useful for diagnoses, andcomprehension of genetic diseases or diseases witha genetic component, comprehension of
epidemiological aspects, help in prevention
measures, identification of individuals with risks todevelop diseases, besides knowledge of the origin
and history from human beings and specificpopulations. However, there is the need to becareful with the segregation of individuals orhuman groups due to the small genetic differencesamong them.
References
1 ) Greely HT (2001) Informed consent and other ethicalissues in human population genetics. Ann Rev Genet,
75:241-253.
2) Cavalli-Sforza L, Menozzi P, Piazza A (1994) The Hystory
and Geography of Human Genes. Princeton University Pres,
Princeton.
3) Neel JV (1973) “Private” genetic variants and frequency ofmutation among South American Indians. Proc Nat Acad
Sci USA; 70:3311-3315.
4) Chakraborty R, Kamboh MI, Ferrell RE (1991) “Unique”
alleles in admixed populations: a strategy for determining
hereditery population differences of disease frequences.
Ethn Dis, 1:245-256.
5) Shriver MD, Smith MW, Jin L et al. (1997) Ethnicaffiliation estimation by use of population-specific DNA
markers. Am J Hum Genet 60:957-964.
6) Futuyma D J (1998) Evolutionary Biology. Third Edition.
Sinauer Associates, Sunderland.
7) Jones, JS (1981) How different are human races ? Nature,
293:188-190.
8) Fullilove MT (1998) Abandoning “Race” as a Variable in
Public Health Research – An Idea Whose Time Has Come.
Am J Public Health, 88:1297-1298.
9) Goodman AH (2000) Why genes don’t count (for racialdifferences in health). Am J Public Health, 90:1699-1702.
1 0) Templeton AR (1998) Human Races: A Genetic andEvolutionary Perspective. Am Anthrop, 100:3.
11) Torroni A, Lott MT, Cabel MF et al (1994) mtDNA andthe origin of Caucasians: identification of ancient
Caucasian-specific haplogroups, one of which is prone to arecurrent somatic duplication in the D-loop region. Am J
Hum Genet, 55:760-776.
1 2) Torroni A, Huoponen K, Francalacci P et al (1996)
Classification of european mtDNA from an analysis of three
european populations. Genetics, 144:1835-1850.
13) Chen YS, Torroni A, Excoffier L et al (1995) Analysis of
mtDNA variation in African populations reveals the mostancient of all human continent-specific haplogroups. Am J
Hum Genet, 57:133-149.
1 4) Torroni A, Huoponen K, Francalacci P et al (1996)
Classification of european mtDNA from an analysis of three
european populations. Genetics, 144:1835-1850.
15) Stone AC, Stoneking M (1993) Ancient DNA from a PreColumbian Amerindian population. Am J Phys Anthrop,
92:463-471.

Eubios Journal of Asian and International Bioethics 16 (January 2006)
1 6) Shriver MD, Parra EJ, Dios S et al (2003) Skin
pigmentation, biogeographical ancestry and admixture
mapping. Hum Genet, 112:387-399.
17) Armelagos GJ (1994) Racism and physical anthropology:
Breves’s review of Barkan’s the retreat of scientific racism.
Am J Phy Anthrop, 93:381-383.
18) Billings PR (1992) Discrimination as a consequence ofgenetic testing. Am J Hum Genet, 50:476-482.
19) Azoulay KG (2003) Not an innocent pursuit: The politics
of a “Jewish” genetic signature. Dev World Bioeth, 3:119126.
20) UNESCO, International Declaration on Human Genetic
Data, 2001.
21) Duda A, Royal C, Secundy MG (2003) The ethical andsocial implicatiions of exploring African American
genealogies. Dev World Bioeth, 3:133-141.

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Editorial address:

Prof. Darryl Macer, RUSHSAP, UNESCO Bangkok,
920 Sukhumvit Rd, Prakanong,
Bangkok 10110, THAILAND
Fax: Int+66-2-664-3772
Email: asianbioethics@yahoo.co.nz
d.macer@unescobkk.org
Send papers to the editor in electronic form if possible.
Please use numbered reference style, do not use automaticfootnotes or endnotes. Papers are peer reviewed.
The journal is independent of UNESCO and the contents are
not endorsed by either Eubios Ethics Institute or UNESCO, but
are published in the spirit of academic freedom.
South-South dialogue is encouraged, and papers outside of
Asia and the Pacific are welcome.

Eubios Journal of Asian and International Bioethics 16 (January 2006)

28

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Eubios Ethics Institute Publications (Books sent by SAL post, Journal by Airmail - Price included)
Eubios Journal of Asian and International Bioethics
Other countries/credit card
Price:

US$35 Euro 35 UK£20 NZ$40 A$40 C$40 ¥3000

NZ$60

Shaping Genes: Ethics, Law and Science of Using Genetic Technology in Medicine and Agriculture
by Darryl Macer, Oct. 1990, 421pp.
Cost: US$20 UK£10 NZ$30 A$25 C$22 ¥2500 Others or credit card NZ$30
Equitable Patent Protection in the Developing World
by William Lesser, May 1991, 150pp.
Cost: US$15 UK£8 NZ$20 A$20 C$17 ¥1500
NZ$25
Attitudes to Genetic Engineering: Japanese and International Comparisons (Bilingual)by Darryl Macer, May 1992 330pp.
Cost: US$30 UK£15 NZ$35 A$30 C$30 ¥3000
NZ$40
Eds: Norio Fujiki & Darryl R.J. Macer July 1992 ISBN 0-908897-03-0 (English),
Human Genome Research & Society
230pp. ISBN 0-908897-04-9 (Japanese), 240pp. Cost: US$20 UK£10 NZ$30 A$25 C$22 ¥2000

NZ$30

Intractable Neurological Disorders, Human Genome Research and Society Eds: N. Fujiki & D. Macer
Feb. 1994 ISBN 0-908897-06-5 (English), 320pp. ISBN 0-908897-07-3 (Japanese), 340pp.
Cost: US$25 UK£12 NZ$30 A$30 C$27 ¥3000

NZ$40

Bioethics for the People by the People
by Darryl Macer,... May 1994 ISBN 0-908897-05-7, 460pp. Cost: US$30 UK£15 NZ$35 A$35 C$32 ¥3000 NZ$50
Bioethics in High Schools in Australia, Japan and New Zealand,
by D. Macer, Y. Asada, M. Tsuzuki, S. Akiyama, & N.Y. Macer
March 1996, ISBN 0-908897-08-1, 200pp.(A4)
Cost: US$25 UK£15 NZ$30 A$30 C$30 ¥2000

NZ$40

Protection of the Human Genome and Scientific Responsibility (Bilingual)
Editors: Michio Okamoto, Norio Fujiki & D.R.J. Macer,
April 1996, ISBN 0-908897-09-X, 210pp.
Cost: US$25 UK£15 NZ$30 A$30 C$30 ¥2500

NZ$35

Bioethics in India (includes 115 papers from Jan.1997 conference)
Eds: Jayapaul Azariah, Hilda Azariah & Darryl R.J. Macer
June 1998 ISBN 0-908897-10-3, 403 pp.
(Printed in India)
Cost: US$30 UK£18 NZ$34 A$36 C$36 ¥3000
NZ$45
Bioethics is Love of Life: An alternative textbook
by Darryl Macer, July 1998 ISBN 0-908897-13-8, 152pp. Cost: US$26 UK£14 NZ$34 A$34 C$32 ¥3000
NZ$40
Bioethics in Asia (includes 118 papers from Nov.1997 conferences, ABC’97 Kobe and Fukui Satellite)
Eds: Norio Fujiki & Darryl R.J. Macer
Cost: US$36 UK£20 NZ$40 A$38 C$40 ¥3000
NZ$50
June 1998 ISBN 0-908897-12-X, 478 pp. October 1999 ISBN 0-908897-14-6 (Japanese), 320pp.
Ethical Challenges as we approach the end of the Human Genome Project
Editor: Darryl Macer, April 2000 ISBN 0-908897-15-4, 124pp. Cost: US$20 UK£12 NZ$30 A$30 C$30 ¥2500 NZ$35
Bioethics Education in Japanese High Schools (in Japanese only)
Editor: Darryl MacerApril 2000 ISBN 0-908897-16-2, 112pp. Cost: US$20 UK£12 NZ$30 A$30 C$30 ¥1000
NZ$35
Bioethics and the Impact of Human Genome Research in the 21st Century
Eds: Norio Fujiki, Masakatsu Sudo, & Darryl R.J. Macer March 2001 (English and Japanese bilingual, 350pp).
Cost: US$30 UK£20 NZ$40 A$38 C$40 ¥3000

Bioethics in Asia in the 21st Century
Eds: Song Sang-yong, Koo Young-Mo & Darryl R.J. Macer
August 2003 ISBN 0-908897-19-7, 450pp. Cost: US$35 Euro35 UK£20 NZ$40 A$38 C$40 ¥3000
Challenges for Bioethics from Asia
Ed: Darryl R.J. Macer
November 2004 ISBN 0-908897-22-7 656 pp. Cost: US$35 Euro35 UK£20 NZ$40 A$38 C$40 ¥3000
A Cross Cultural Introduction to Bioethics January 2006, 300pp. (A4)
Editor: Darryl Macer

Cost: US$35 Euro35 UK£20 NZ$40 A$38 C$40 ¥3000
all journals + all books ++ (English version) US$190

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