Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 22 (2) March 2012www.eubios.info

ISSN 1173-2571

Official Journal of the Asian Bioethics Association (ABA)
Copyright ©2012 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page

Editorial Note: End of Life Care – Darryl Macer
49
Death with dignity is impossible in contemporary Japan:
Considering patient peace of mind in end-of-life care49
- A. Asai, K. Aizawa, Y. Kadooka, and N. Tanida
Three Level Structure Analysis of End of Life Care in Japan 53- Sawa Kato
Advance Directives in Hong Kong: ethical perspective
58- Wai Yan Law
Death Anxiety in University Students
65- S. Kadioğlu, O. Ögenler, F. Kadioğlu, Mehmet Ali Sungur
Bioethics in the Islamic Republic of Iran69
- Nader Ghotbi
Policy Analysis of Measures Taken Against the H1N1
Influenza Virus of 200975
- Shinya Ueno
Bioethical issues and HIV stigma - S. Nithianandam
81
Consideration of issues concerning “Physician’s Prescriptions”
in the Practice of Occupational Therapy in Japan82- Katsuaki Yamano
The Present State of Commercial Surrogacy in India and the
Ethical Assessment of Physician in Charge Dr. Nayna
Patel―Ethical Research concerning Indian Reproductive
Medicine, Especially Commercial Surrogacy
85- Masayuki Kodama
ABA membership
91

Editorial Note: End of Life Care
The first three issues of EJAIB for 2012 include
papers from the Fifth UNESCO-Kumamoto University
Bioethics Roundtable, held 3-5 December 2011 in Japan.
The March issue focuses on papers on end of life care
and advance directives. There are also some papers
submitted to EJAIB on related topics, and a couple ofother papers on medical ethics issues including H1N1
policy in Japan, and surrogacy tourism and HIV in India.
The authors describe different cultural perspectives
that affect bioethical decision making, from individual
beliefs and experiences to policy and law. , and explore
ways that ethical principles can be applied to decision
making regarding the end of life care and bioethics inJapan, Hong Kong, Turkey and Iran.
- Darryl Macer

Please renew your Asian Bioethics Association
subscriptions for 2012, and submit abstracts to the13th Asian Bioethics Conference, 27-31 August 2012
in Kuala Lumpur, Malaysia.
Editorial address:
Prof. Darryl Macer, Director, Eubios Ethics Institute,
c/o Center for Ethics of Science and Technology,
Chulalongkorn University, Faculty of Arts, Chulalongkorn
University, Bangkok 10330, Thailand
Email: darryl@eubios.info

Death with dignity is impossible
in contemporary Japan:
Considering patient peace ofmind in end-of-life care
- Atsushi Asai, Kuniko Aizawa, Yasuhiro Kadooka, andNoritoshi Tanida- Atsushi Asai (corresponding author), Department of Bioethics,
Kumamoto University Graduate School of Medical Science,
Kumamoto University, Kumamoto, 1-1-1 Honjo, Kumamoto,
860-8556, Japan
E-mail: aasai@kumamoto-u.ac.jp

Abstract
Currently in Japan, it is extremely difficult to realize thebasic wish of protecting personal dignity at the end of life.
A patient’s right to refuse life-sustaining treatment has
not been substantially warranted, and advance directives
have not been legally enforceable. Unfortunately, it is not
until the patient is moribund that all concerned parties
start to deliberate on whether or not death with dignity
should be pursued. Medical intervention is often
perceived as a worthwhile goal to not only preserve life,
but also provide psychological benefit to the family,
regardless of its effect on the patient. To feel they are
doing something, family members tend to act against theimperative “Do not inflict on others what you would notwish done to you,” and permit extraordinary measuresthey would not want themselves. Another complication in50

Eubios Journal of Asian and International Bioethics 22 (March 2012)

Japanese culture is the necessity of unanimous decisions
for end-of-life care. If there is conflict between a patientand his/her family on accepting medical intervention, theview of the latter is more likely to prevail due to different
perceptions of human dignity. As a result, incapacitatedpatients in Japanese clinical settings often suffer throughextraneous medical procedures, particularly during endof-life care. Patient dignity is in danger from a national
refusal to accept major bioethical principles such as
having respect for patient autonomy, serving the bestinterests of the patient, doing no harm, and ensuring
fairness at the end of life. We argue that more education
about human dignity and legislation for death with dignity
are necessary. Peace of mind for patients during end-oflife care will never be achieved in this society unlessdrastic changes take place in medical ethics and law.
1

1 Introduction
A peaceful, natural death, or death with dignity, is ofgreat interest in contemporary Japan. The deaths offamous people are frequently reported in detail by news
media, and special feature articles and issues on ideal
ways of dying are popular. Some physicians have evenraised questions about end-of-life care in books withimpressive titles such as “Peaceful Death (Heion-shi),”“Satisfactory Death (Manzoku-shi),” and “Time to Die for
the Japanese (Nihonjin no Shinidoki).”(1-3) Theseauthors argue that a longer life span does not necessarily
result in a happier life and makes it more difficult to diewith peace and satisfaction. They claim that current endof-life care in Japan needs reform.
We argue that the preferences of patients and theJapanese public towards end-of-life care have not been
sufficiently respected and that inappropriate medical
intervention severely damages human dignity in the final
stages of life. Both UNESCO’s Universal Declaration on
Bioethics and Human Rights and the World Medical
Association Declaration of Lisbon on the Rights of thePatient clearly state that a patient’s human dignity must
be protected and respected (4, 5). Nonetheless, factors
other than ethical disagreement can obstruct decisionmaking and lead to difficult situations.
In this paper, we point out the psychological, social,legal, and ethical dimensions of terminating medical
intervention as related to death with dignity incontemporary Japan. Human dignity and death with
dignity are discussed, and their current trends anddifficulties are described. We also introduce practicalquestions and answers on termination of medical
intervention formulated by American bioethicist E.J.
Emanuel (2011) (6) and consider problematic
circumstances specific to Japan. Finally, six underlying
causes for current attitudes on death with dignity aresuggested. We conclude that present end-of-life care in
Japan damages human dignity and requires urgent
reform through education and legislation to promote
peace of mind for all concerned parties.
1th

This paper is based on presentation at the 5 . UNESCOKumamoto University Bioethics Roundtable (December, 2011,
Kumamoto, Japan) and is a shortened form of an originalarticle, “Imano Nippon deha songenshi wa fukano” written in
Japanese, to be published in the Journal of Hospice care andHome care, 2012.

2 Human dignity and death with dignity
The concept of human dignity has become the basis for
ethical, legal, and social judgments, as well as criticismsof medical treatments and research. The Declaration of
Helsinki states that, “it is the duty of physicians who
participate in medical research to protect the life, health,dignity, integrity, right to self-determination, privacy, andconfidentiality of personal information of researchsubjects (7).” Section 10 of the Declaration of Lisbon
similarly states that “the patient's dignity and right toprivacy shall be respected at all times in medical careand teaching, as shall his/her culture and values (5).”Gastmans et al. argue that “clinical ethicists must
interpret clinical reality in the light of human dignity,” thus
placing the concept at the root of clinical ethics (8). The
meaning of human dignity is ambiguous, however, withvarious proposed definitions.
The first definition acknowledges that dignity is part ofhuman existence itself (9). Christianity recognizes humanvalues on the basis of being created in God’s image;therefore, dignity is considered a fundamental concept
and source of personal freedom and human rights (10).
Dignity is an absolute value people possess as long as
they are human, and it has been argued that everyone
should have mutual respect for the dignity of others (11).
Consistent with this school of thought, human dignity isgiven the highest priority and should never be opposedby secular, selfish considerations.
A second school of thought suggests that dignity is apart of human attributes such as a rational mind,
autonomy, and self-selection. Socrates and Aristotle
believed that human dignity resided in deep thinking,self-consciousness, and the ability to choose freely (12).
Some moral and ethical viewpoints consider dignity as acollection of intangible, distinctly human goods (13). In
addition, some authors list virtue, consistency, and prideas part of an individual’s dignity (11). They define dignity
as “humanness,” “being free,” “not feeling miserable orhumiliated,” or “living without losing human pride (14).”
Others may disagree with those definitions; in fact, many
would argue that people who lack the above
characteristics still possess human dignity.
A different perspective reveals at least two uniqueconcepts of dignity; one is “inherent dignity,” where every
person has as a universal and inalienable moral quality
which cannot be earned or taken away, and the second
is “individualistic dignity,” which is tied to personal goals
or social circumstances and can be enhanced ordiminished depending on circumstances. These conceptsof dignity can be assaulted by events outside the controlof the person involved, such as a debilitating disease(15). A commentator has also proposed “dignity ofidentity” as the dignity we attach to ourselves as
integrated and autonomous people with a history, future,and relationships to other human beings (16). This dignity
is strongly associated with self-respect and feelings ofworth (17).
Human dignity thus appears to have no definite
characteristics that are universally agreed on. There is noconsensus as to what human dignity really is, what
conditions are considered to be dignified, and what
constitutes a violation of human dignity. Nonetheless,Eubios Journal of Asian and International Bioethics 22 (March 2012)individuals usually feel they possess some form ofdignity; they have a sense of their own importance, pride,virtue, and a belief that there is something important intheir lives. One could speculate that most individuals
have some notion of their own dignity, if not a clear-cut
definition.
Another important connotation to consider is thatpeople should respect others’ human dignity as
something everyone should mutually respect in eachother. The Dignity Principles from the British Medical
Association Ethics Department explain that “patientsshould be treated with respect and courtesy, and theirsocial and cultural values should be respected (18).”
Inconsistency between one’s own dignity and theevaluation of others’ dignity becomes a serious problem
related to end-of-life care. For example, a person may
lose their dignity and thus hope to die; however, others
might feel there is still dignity and forcibly prolong theindividual’s life. These two perspectives of human dignity- what people actually feel about themselves and what
others identify in them - thus stand independent of eachother.
We believe human dignity is defined as values in spirit,morality, and character that humans possess precisely
because they are humans, and which people can takepride in and stand on. We would also argue that deathwith dignity is a way of dying that allows a terminal
individual to feel and maintain dignity until the final
moments. For those who suffer consciousness
disturbance, death with dignity could be a way of dyingthat convinces a sympathetic family that the patient’s
dignity was appropriately respected. We feel that what ismost important for an individual receiving medical care is
the feeling that his or her dignity is protected andrespected. It is also important to avoid situations where apatient feels they would rather die. Finally, the patient’s
dignity outlook must be given priority over the outlooks ofothers. We believe human dignity is the most importantvalue a patient has in the clinical setting.
3 Domestic social tendencies and ethically difficult
situations
For a long time, Japanese clinical settings haveconfronted several difficult situations with discontinuinglife support. Police investigated doctors over the past
twenty years who removed coma patients from
respirators at the end of their life, and all cases resulted
in the issuance of judicial documents. No physician has
been prosecuted so far, but concerns among healthcare
professionals on the discontinuation of artificial
respiration remain great. Hospital ethics committees inJapan have given priority to legal concerns rather thanethical ones and tend to propose policies that do not
admit to cancellation of medical intervention procedures
such as artificial respiration or tube feeding. We argue
that this represents timidity and avoidance of ethicaljudgment, which can lead to ignoring the human rights ofthe patient. Even if an expert in clinical ethics judges thecancellation of life support to be ethical, an ethics
consultant would then have to explain the current legal
concerns in Japan to the medical professionals. Because
the withdrawal of artificial respiration by a doctor torespect patient wishes was substantially impossible and51

the ethics committee could not reach a conclusion, a
tragic incident occurred when a family member turned off
her son’s artificial respiration instead and was foundguilty of murder (19).
Kodama wrote that “the medical person who performed
cancellation and withholding of life support has been
judged for murder after the fact without being shown legal
judgment beforehand. I cannot but feel the absence ofthe law, and this situation is absurd (20).” Actually, nolaws against cancellation of life-sustaining procedures
have ever existed in Japan. The courts tend to apply
criminal law on assisted suicide and murder selfrighteously and forcibly, even though death with dignity
differs from euthanasia. We cannot regard Japan as aconstitutional state in this context.
Table 1 Practical questions by Emanuel and current
situations concerning end-of-life care in both theUnited States (6) and Japan (by the authors)
Is there a legal right to refuse medical interventions?
US
YES
JPN
Uncertain (substantiallynone)
What interventions can be legally and ethicallyterminated?
US ANY and ALL JPN
Probably none of lifesustaining interventions
Is there a difference between withholding life-sustaining
interventions and withdrawing them?
US
NO
JPN
YES (withdrawing is
unacceptable in principle. Or bothmight be unacceptable depending on
the kind of interventions)
Whose view about terminating life-sustaining
interventions prevails if there is a conflict between thepatient and family?
US
The views of a
JPN
Case-by-case, andcompetent adult patientcollective decision-making
prevail.
is predominant
Who decides about terminating life-sustaining
interventions if the patient is incompetent?
US
Appointed proxy or JPN
Family membersa legally designatedwithout clear hierarchy orhierarchy: (1) spouse, (2)border, depending on
adult children, (3) parents,
power balance among the(4) siblings, and (5)members
available relatives.
Are advance care directives legally enforceable?
US
YES
JPN
no laws of this matter exist
4 Six factors that hinder death with dignity incontemporary Japan
Table 1 displays current situations concerning end-oflife care in both the United States and Japan (6). Six
factors in particular could prevent death with dignity as
defined above for end-of-life care in Japan.
4-1 Absence of law
As previously discussed, no written legal regulation
concerning termination of medical intervention has
existed to date in Japan, and healthcare professionals
are uncertain about which actions are forbidden. The
Tokyo High Court declared in the Kawasaki Kyodo
Hospital case that patient self-determination, family

52

Eubios Journal of Asian and International Bioethics 22 (March 2012)surrogate decision, or the limits of a physician’s
obligation to treat were not decisive grounds to support a
legitimate termination of life support. They also claimed
that withdrawal of life support would go against laws
prohibiting murder at the victim’s request and assisted
suicide (21). In addition, no legally enforceable advancedirectives have existed in Japan so far. A relevant bill
was once presented to the Diet in 2007, but no further
discussions have occurred.
4-2 Certainty of impending death
When death is not immediate, the right to refuse lifesustaining treatment is not considered at all incontemporary Japan. The certainty of impending deathappears to have become the main prerequisite forrespecting patient decisions. In addition, no court,
legislation, or guidelines have ever presented a clear
time limit or precise definition of “impending.”
The Yokohama High Court argued that the possibility ofrecovery always exists, and a doctor should continue
medical intervention unless the chance of survival isabsolutely zero. That a physician should do his/her bestand everything possible to save a patient even with slim
odds of survival is not only a medical duty, but could also
be a broader and non-professional obligation (21).
We believe the attitude of the court influences all
ethical judgments about death with dignity from the start.
Their decisions do not consider the principle that medical
treatment is determined by the patient. Regardless ofdeath, medical treatment should ultimately be an arbitrary
power matter for the patient or their decision-making
caretaker. However, death with dignity is currently
recognized only after it becomes useless for anyone, andhuman dignity is stained thoroughly.
We cannot understand why the degree of terminal
prognosis is connected to the permissibility of death with
dignity. Such thinking equates to a position that accepts
the sanctity of life as a firm premise, with no reflection orquestioning of the death with dignity argument. A judicial
requirement of certainty for imminent death forgets that
medical care is fundamentally fraught with uncertainty.
There is a strong possibility that definite determination ofimpending death makes death with dignity in Japan
extremely difficult.
4-3 Problematic distinctions
In general, the termination of medical intervention has
become a great social issue with accompanying
attention. The police investigate, and then media tend torush to a hospital and report that "euthanasia was
performed." Attitudes on withholding life-prolonging
treatment are not clear, although there are big social andlegal differences compared to withdrawal. The difference
does not ethically exist, however, since both actions havethe same effect from a patient’s perspective. Death with
dignity is compatible with many ethical guidelines
worldwide and the views of most bioethics scholars, but
healthcare professionals bear a heavy psychologicalburden if their society does not consider the act to be
just. Distinction issues also exist between ordinaryintervention measures and extraordinary ones.
4-4 Unanimous decisions

When the opinion of the family differs from that of thepatient, patient intent may not be given priority in Japan.
Life-prolonging measures may thus continue at therequest of the family even when death becomes certain
because medical treatment policies give more weight tounanimous decisions rather than self-determination. “ThePrinciple of Harmony (Wa no Seishin)” overshadowed
respect for autonomy in most human interactions,
including clinical ones, until now (22). When a patient has
strong family relations and/or very clear intentions about
medical care, self-determination can be sufficiently
respected; however, the situation could easily changewith domestic power relations or balance. At the end oflife, those too physically, mentally, or socially weak toexpress their wishes are most damaged by inappropriate
medical intervention imposed by others (19).
4-5 Principle of intervention
Medical intervention for incapacitated patients may becontinued as psychological assistance for their family.
Ishitobi wrote, “Family members would want to avoid afeeling of regret such as ‘We have left this or that
undone’ after the patient’s death.” This regret tends tosteer family members away from less aggressiveintervention and a “natural course of dying. (1)” With lifesustaining procedures, they could feel they did all they
possibly could for the dying family member. In thissituation, the personal satisfaction and peace of mind of
the family members seem central to decision-making,particularly if they are not close to the patient.
We would argue that in these circumstances, medical
intervention became a valuable purpose for the family to
pursue. When intervention or “doing something” becomesthe goal itself rather than a successful outcome for thepatient, extraordinary measures never become uselessor futile since an unconscious benefit is alleviation ofregret for the family. There appears to be an intervention
principle involved where doing something is better thannothing, regardless of consequences. However, doing
something harmful or burdensome to patients to easefamilial regret is a serious abuse of medical intervention,even if the family has psychological needs.
4-6 Double standard
Japanese culture traditionally permits a double
standard in decision-making, often viewed as deep
consideration or a caring attitude for others. A recent
national survey conducted by the Ministry of Health,Labour, and Welfare revealed that the percentage of
people who want to refuse life-sustaining treatment forthemselves is about 20 percentage points higher thanpeople who want to refuse it for their family (23). Thisdifference in attitude has been recognized for a long timein the research and clinical experiences of doctors (2426).
5 Conclusions
The ethical quality of a nation’s healthcare system canbe evaluated by how compatible its ethical norms arewith long-accepted universal bioethical principles. We
believe that unanimous and collective decision-making
fails to respect personal autonomy, that extraneous
medical intervention goes against the principles ofEubios Journal of Asian and International Bioethics 22 (March 2012)
beneficence and doing no harm to a patient, that there isa double standard for patient justice and fairness, andthat the standard of certainty for impending death
completely violates ethics and human dignity.
From the stance that protection and respect for humandignity are extremely important in medical care, a system
which can respect these values is more desirable than
one which cannot. If the present healthcare system inJapan can injure patient dignity, it should be corrected,
which we believe is starting to happen. If even a minorityof patients facing end-of-life care hope for a natural anddignified death, their intentions must not be ignored
without sufficient cause.
Even if there is no drastic strategy to change attitudes
on human dignity and death with dignity, education andlegislation are needed at the very least. Japan needs anationwide program that educates laypersons andhealthcare professionals, enabling them to recognize
medical uncertainty and useless or futile medical care,consider the purpose and consequence of medical
intervention, and accept different outlooks on humandignity from others. People must learn that it isinappropriate to perform life-supporting measures on apatient just for the well-being of the family. Further
legislation is also needed for advance directives,
termination of medical intervention, and patient selfdetermination. Otherwise, pending cases that ignore
patient dignity will not disappear. Patient peace of mind
during end-of-life care will never occur unless drasticchanges take place in the medical ethics and laws of oursociety.
References
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2 Okuno S. Manzoku-shi: Netakiri zero no shiso [A satisfactory
death: the principle of no bedridden elderly.] Tokyo:
Kodansha, 2007.
3 Kusakabe Y. Nipponjin no Shinidoki: Sonnani nagaiki shitai
desuka [Time to die for Japanese: do you want to live solong.] Tokyo: Gentosha, 2007.
4 UNESCO. Universal Declaration on Bioethics and Human
Rights. 19 October 2005.
5 World Medical Association. WMA Declaration of Lisbon on
the Right of the Patient. Santiago, 2005.
6 Emanuel EJ. Bioethics in the practice of medicine. In L.
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ed. Philadelphia, PA: Elsevier/Saunders, 2012.
7 World Medical Association. WMA Declaration of Helsinki.
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8 Gastmans C, Milisen K. Use of physical restraint in nursing
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9 Kilner JF. Human dignity. In SG. Post (Ed.,) Encyclopedia ofrd
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10 Mitsuishi T. Ningen no songen to jinken no kankei [Arelationship between human dignity and human rights.]
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11 Takahashi T. Hito-hai mondai heno “hanseiteki kinko” notekiyo [An application of “reflective equilibrium” to issues
about the human embryo.] T. Takahashi (Ed.,) Hito-hai no
Seimei to Ningen no Songen [The life of the human embryoand human dignity.] Fukuoka: Kyushu University Press, 2002:
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12 Sector for Social and Human Sciences Division of Ethics ofScience and Technology. Bioethics Core Curriculum Section
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ethics.] Tokyo: Medical Friend-sha, 2004: 185-190.
15 Pullman D. Human dignity and the ethics and aesthetics ofpain and suffering. Theor Med Bioeth 2002; 23: 75-94.
16 Nordenfelt L. The varieties of dignity. Health Care Anal
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17 Prinsen EJ, van Delden JJ. Can we justify eliminating
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Ethics Today: The BMA’s handbook of ethics and law, 2 ed.
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19 Tanida N. Denial of death in contemporary Japanese: from a
traditional view of life and death and unrealistic expectationsof modern medicine. J Philos Ethics in Health Care Med
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20 Kodama Y. Seimei-iji chiryo no chushi to sashihikae: “ho” noyakuwari ha nanika [Termination and withholding of lifesustaining treatment: what is the role of law.] M. Takahashi,
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Three Level Structure Analysis of
End-of-life Care in Japan-Sawa Kato, Ph.D.
Consultant, RUSHSAP, UNESCO Bangkok
Email: sawakato@yahoo.com

Abstract
This paper is one part of the group research into
“Bioethics in Asia Based on Three Level Structure
Analysis” and aims to explore the Japanese structure of
end-of-life care according to the analysis way Takahashi
provided. This follows research by Asai (2011) who
considered about the quite different responses for
artificial nutrition and hydration (1), extracted the different
concepts, SOL and QOL, which support for each
response (2) and then analyzed the more basic ideas

54

Eubios Journal of Asian and International Bioethics 22 (March 2012)

which underlie those concepts (3). We will share the firstpart with Asai approach but this paper will follow a
different route about the other parts. It will move from (1)to (3) and from (3) to (2).
The main purpose is to explore Japanese ideas which
underlie concrete moral judgments of end-of-life care. We
will consider about the Japanese concept of inochi andoverview how it is applied in the traditions of Shinto or
Buddhism in Japan. SOL and QOL which are arguably
imported concepts will be interpreted based on theJapanese concept of inochi.
The analysis of the Three Levels Structure by Asai
Asai (2011), a Japanese physician and bioethicist,
analyzed the arguments for and against artificial nutritionand hydration (ANH) for elderly people who cannot eat
and presented a model of the three levels structure in
2
Japanese end-of-life medicine. By referring to hisanalysis, the structure of three levels will be overviewed.
The concrete moral judgments whether ANH should be
provided for the elderly who cannot eat, when the will of
the patient is unknown, belong to the first level. Asai
extracted the moral values in those judgments for andagainst ANH. The opponents’ arguments emphasize “thesignificance of being natural, acceptance of the natural
span of life, importance of considering the patient‘s QOL
and interests, utility of medical interventions, criticism ofmere life-prolongation, and necessity of personhood andself-awareness” (Asai, 2011, p.40). In contrast, theproponents of ANH stress “vulnerability of the elderly,
absolute prohibition of discrimination, categoricalprohibition of discontinuing ANH, discontinuation of ANH
being equivalent to murder, human rights such as theright to live, and unconditional prohibition of value
judgments on human lives” and claim “The term of“natural death” is deceptive and the truth is that it ismurder” (Asai, 2011, p.40).
The second level consists of the ethical principles andnorms which form the basis of the concrete moral
judgments at the first level. According to Asai, thedifferences between proponents and opponents of ANH,
“can be simplified to those who support QOL and those
who support sanctity of life (SOL). In other words, this isconfrontation between those who approve of theevaluation of QOL for patient… and those who forbid it”(Asai, 2011, p.40).
The third level includes the more basic theories,
principles, and concepts that ground the principles andnorms at the second level. Asai pointed out utilitarianismand non-religious SOL doctrine as the third levels. “QOL,
subjective happiness, personhood, sentience, interestsand utility are key concepts are values in utilitarianarguments” (Asai, 2011, p.40). In contrast, “Supporters of
the non-religious SOL doctrine would highly value ofwarmth of patients and their existence” (Asai, 2011,p.40).
As he analyzed, the concepts of QOL and SOL often
play an important role in Japanese medicine andbioethics, especially in the ethical arguments of terminal
care
andwithdrawing/withholding
life-sustaining
2

See Takahashi (2011) about the details of the three levels
structure and the relationships among each level.

treatments including ANH. Both can be said that they areat the second level and they form our concrete moral
judgments. However, both the utilitarian theory and SOL
doctrine at the third level are rooted in the western ethics
and, as it were, imported from western bioethics. They
may share some part with Japanese bioethics andtherefore they are powerful in Japanese medicine.
However, even if they look like explaining the ethicaljudgments of ANH, the different ethical theories andprinciples to explain them better might be hidden andsuch theories and principles are seen in Japanese
3
ideas.
The purpose of this paper is to explore the more basic
background at the third level from Japanese ideas. It will
be expected that such a background is able to sharesome part with the imported concepts of QOL and SOL
and at the same time explain the Japanese original andtraditional thoughts.
Desire for a natural death
Our analysis using the three levels structure in
Japanese end-of-life care begins with the attention to theidea of “natural death” or “being natural in dying.” As wehave seen above, the reasons given by the opponents of
ANH included, “the significance of being natural” and“acceptance of the natural span of life.” It seems to imply
that ANH is a kind of extraordinary medicine and“unnatural.” At the same time, in the argument of the
proponents of ANH is seen the attitude that once ANH isstarted, the termination of it results in the patient’s deathby the human intentional act and it is equal to murderand (Asai, 2011, p. 39). It seems to imply that ANH is oneof ordinary medicine and withholding/withdrawing it isequal that the patients let to starve to death. They denythat it is “natural death.”
After the state of California enacted “The Natural DeathAct” in 1976 for the first time, the term was given a newmeaning which people can deny the life-sustaining
treatment in advance and has been associated with4
death with dignity. Originally, it meant the natural way ofdeath by natural causes, such as dying of old age or
disease based on the internal causes, compared withdeath is caused by external causes, such as accident(manmade or natural disaster) or homicide. About
suicide, the evaluation may be divided as we will see thispoint below. Withholding and withdrawing ANH seems tobe associated with such a way of dying.
Suppose that the opponents and proponents of ANH
share their basic attitude that let dying people get die“naturally,” but then the contents of dying “naturally” aredifferent, we will start to analyze the three levels
5structure. The background why such different contents
3

Takahashi also wrote that “Researchers of philosophy refer tothe third level, but they tend to neglect cultural differences of
medical practices, and rarely look back at Japanese traditional
thoughts” (Takahashi, 2011, p. 2).
4
In some Japanese guidelines or official reports, “death of
dignity” is described as a kind of natural death resulted by the
avoidance of extraordinary medicine. For example, see the2008 report of the Science Council of Japan (｢終末期医療のあり方について―亜急性型の終末期について―｣).
5
A type of claims that “X is unnatural and therefore X is
ethically wrong” has been seen in bioethics arguments inEubios Journal of Asian and International Bioethics 22 (March 2012)
are brought will be sought in Japanese traditional
thoughts. Therefore, we will consider about the third level
next.
Japanese views of life (inochi) and deathWe will use the Japanese word inochi instead of life.
Inochi corresponds to the word of life in English. Another
word, seimei, has almost the same meaning. Seimei wasa translated word from “life”, “Leven”, and “vie” in 19th
and now it tends to be used in scientific or academic
context. Inochi has been used since ancient times andeven today it is in common use. Compared with seimei,
inochi is ordinary and popular (Morioka, 1991, p.87).
The origin of inochi is said that “i” means breath and“chi” means power and inochi stands for the power ofbreath. Breathing was the clear evidence that a being isalive. It was also clear that a being dies naturally whenbreath stops. In ancient Japan, inochi had a wide range
of usage; the power of living, lifespan, lifetime, destiny,
6and time of death. The idea of death is seen directly andindirectly in those usages. Under the Japanese concept
of inochi, the ideas of life and death include the image ofa connection through breath, rather than a disconnection.
Inochi is equally given to all beings (humans, animals,
and plants), not by God, but from somewhere. According
to the tradition of Shinto, the Japanese indigenous belief,
death is one form of kegare that is a kind of uncleanness
or dirtiness and therefore should be hidden or kept awayfrom daily life. Death as a kegare was one of the worst
events which threatened and broke the order of daily life.
Therefore, ancient Japanese were afraid of death andmade it a taboo subject for discussion. There are a lot of
expressions implicitly meaning human death, because
using the word death or die directly is taboo.
Since Buddhism was introduced from the Asian
continent in the 6th century, the Shinto view of death wasaffected. In Buddhism, there are four major sufferings;
living, aging, being ill and dying. Living is a full ofsufferings and being alive are always changing to dying.
Nobody can escape from such a stream. Basically,
Buddhism preached people to stop caring about
inevitable sufferings and accept that such is life, and thatas a result peace of mind can be achieved. It claimed
7
that all beings have the potential to attain enlightenment.
For ancient people who were afraid of death, thoseguidance from Buddhism would be a saving for bereleased from the fear. It can be interrupted that giving up
resisting sufferings and taking an attitude of resignation
could result in being released from them and as a result
being saving by Buddha.
Another way of overcoming the fear of death can beseen in the Japanese history. Samurai as a career,
traditional Japanese warriors, were always conscious ofdeath, especially in fighting. Samurai needed toJapan. They are often criticized that such a claim is not logicallyvalid because the meaning of “unnatural” is not clear. Our
discussion is related to such a type of claim but it aims to makeclear the contents, not the validness.
6
Iwanami kogo jiten, p.125,｢命｣((1)生命力、(2)寿命、(3)一生・生涯、(4)運命、(5)死期). Nishida (2009) pointed out that themeanings of (2), (4), and (5) imply the idea of death.
7
一切衆生悉有佛性.

55

overcome the fear of death and were prepared for deaththemselves. This can be seen as the conquest of the fearof death by self. Samurai also affected Buddhism, butthey developed an original style since Kamakura Era (12century) (Watsuji, 1979, 306). Being prepared for death isrelevant to seppuku (hara-kiri) in the tradition of samurai
as a type of suicide. Seppuku has not been viewed in anegative light.
The death for samurai was not that it comes in the
future necessarily, but that it comes suddenly. Wheneverit comes, it was always needed to be prepared for own
death. It meant to set one’s heart on own death inadvance (Sagara, 1984, p.116). When their lords werebrought to a crisis, they fight risking their lives. Whenthey failed to save their lords, they conducted seppuku to
be responsible for it. Not saving their lords but being alive
were a kind of shame and unwillingness.
When samurai got mentally prepared for death, they
became to realize the authentic self (Sagara, 1984,
p.117). It meant that the authentic self was not to have
two faces and, that is, continue to manifest the truth if
their loyalty to the lords all their lives Therefore, to die for
their lords or to follow the lords’ death without hesitating
and getting upset can be interrupted as honorable andgraceful. Though seppuku, samurai could prove to
manifest the loyalty and the authentic self. Takahashi
said that it was a kind of death with dignity andexpressed the ultimate level of freedom underlies thecontrol of own life and death (Takahashi, 2008, p. 113)
The mental preparation of samurai had a priority overmaintaining their lives. It seems that such an attitude has
not lost completely yet in modern Japan. Maresuke Nogi
(1849-1912) who was a soldier committed seppuku,
shortly after his lord, the Japanese emperor at that time,died. When his lord died, his role playing in this world
also finished. A novelist, Yukio Mishima (1925-1970) also
conducted seppuku after hebarricaded himself in acamp of the Japanese Self Force and claimed histhought which Japan should recover the political order
based on the Emperor. Some people commit suicide8
because they think it takes responsibility for their faults.
Other people surrounding them feel their death is sadand have sympathy, and it seems that they understand it
to some degree, even romanticizing it. In those cases,
something more valuable than the maintenance of life
looks like existing. That would be the mental preparationor the strong will of committing suicide. Some otherpeople would respect them although they are sorry for
their death, and others criticize those who take their lives
as an easy way out of their troubles.
Respecting the mental preparation and the strong may
underlie the acceptance of self-determination in Japan. If
decision-making sacrificing someone’s own life looks
unreasonable or irrational, the decision might reflect
something valuable for him/her. It might be needed tokeep the authentic self. It seems that the selfdetermination is respected not because the decision isreasonable and rational, but because the strength of themental preparation or will.
In modern Japan, ancient Shinto and Buddhism haveinfluenced each other and co-existed peacefully, rather
8

shinde wabiru.

56

Eubios Journal of Asian and International Bioethics 22 (March 2012)

than conflicted. The guidance from Buddhism does notrelease the people from the fear of death completely.
Many people suffer from worldly desires and have still thefear. However, we have seen the possible two ways torelease them from the fear; one is the saving by Buddha
and the other is the conquest by self.
SOL, QOL and communal inochi
The ideas of SOL and QOL are imported concepts but
they have become important and even essential todiscuss end-of life care in Japan. It would be safe to saythat they are at the second level which includes principles
to judge or decide the method of terminal care. On thebasis of the arguments of the third level above, theJapanese views of SOL and QOL would be reconsidered.
Those views would be familiar with the Japanese concept
of inochi, rather than life.
In the western concept of SOL, life is given by God andespecially human beings were created from the image ofGod. Therefore, human lives have a special value andare sacred, compared with other lives. In contrast, inochi
was given to all living beings from somewhere. Where isinochi from? Shuichi Kato (1977) wrote that Japanesepeople possess a common image that inochi is produced
from a great and dynamic stream and returns there when
it finishes. Then, inochi finally is assimilated into the9stream. It is often said that we are born from nature, livewith nature and return to nature. As we have seen above,
when people face such a stream they have an attitude ofresignation, however, that everyone eventually returns tosame place could soothe in a sense.
It was believed that young children under 7-years-old
10belong to this world, as well to another world. That ispartly because the rate of death of young children was
higher. When children died young, people believed thatthey returned to the place from which they came. Even
adults died suddenly because of a various causes. Inochi
was fleeting in one hand and therefore Japanese people
have traditionally lives in dread of the end of inochi.
On the other hand, inochi is powerful and dynamic, as
the original meaning was the power of breath. Such animage remains in its modern usage. For example, theexpressions of “network of inochi” or “relay of inochi” candescribe the property that an inochi is incorporated into
something big or that it is individual but at the same time
is not simply individual. An inochi has the close
connection with other inochis in this world (“network of
inochi”). The concept of inochi has not only thecomtemporary extent but also timeless extent. An inochi
is relevant to other inochis, old or new (“relay of inochi”).
Japanese people have worshiped their ancestors and,after they die, their descendants will worship them in turn.
These images of inochis’ extent, at the same time, canbe explained from the Buddhism idea, Pali. A Sanskrit
Pali means that all things do not have any stable
substantiality and they exist under a condition by various
9

Takahashi pointed out such an image shared in a Greek word,
zoe. He distinguishes zoe from bios means for a individual lifeand calls zoe as radical life (Takahashi, 2009, pp172-3).
10
nanasai madeha kami no uchi (｢7歳までは神のうち｣). In
modern, people have a ritual custom to thank children’s safe
growth. It usually is completed when children become 7 years
old.

11

cases, affecting each other. An inochi is unique andirreplaceable because it is firmly incorporated into the12
network and is not separated from it. In this meaning,inochi can be communal.
Based on those interpretations of inochi, the Japanese
SOL can be reconsidered. Inochi has the dynamic powerof breath which enables to be alive by itself, but it isfleeting. Once the power of inochi was lost, it cannot berecovered and therefore it should be respected.
Moreover, an inochi is unique irreplaceable because it isfirmly incorporated into Pali and is supported by the past,present, and future networks of inochi. Finally, an inochi
is assimilated in some big stream after it finishes. As far
as a patient continues breathing, the inochi does not lose
the power of breath yet, as if the dynamic power looks
decreasing. When the power fully is lost, it can mean thenatural end of inochi.
The same aspect of inochi would support for thedecision to reject the prolong life treatment with artificial
respirator. Such a decision can reflect that they want todie when the power is lost. It can be anotherinterpretation of dying naturally. The concept of QOL also
can be understood based on Japanese tradition. As wehave seen the samurai’s or other people’s mental
preparation for death above. In fact, according to asurvey, it is said that the fear of death is decreasing, as
13
people become older.
It can expresses a generaltendency that Japanese people start to prepare for own
death gradually.
However, there are many diverse situations where
patients are in the terminal phase. Everyone does nothave such a strong preparation or they waiver between
life and death when it comes to the point. The network of
inochis makes patients in terminal phase to feel theexistence of other members of the family strongly. It may
be said that Japanese people have aimed to die well or
have a good end of life in the community to which they14
belong. Some try to avoid troubling other members offamily, economically or mentally. Other refer to theirsocial roles or what they did not do in their life (Takeda &Futoyu, 2006). Those indicate that the Japanese way ofevaluating QOL is connected to relation with otherpeople, rather than not completely subjective evaluation
by an atomic individual. Inochi was not simply individual.
The evaluation of QOL looks like being made by a social
15
individual incorporated into the network of inochis. We
can also say that in most cultures the ideal death is one
surrounded by family members, binding their inochi
together.
11

縁起 (Engi).
Morioka also extracted one property of of inochi as being
irreplaceable (Morioka, 1991, p. 100).
13For
example,see
http://group.dai-ichilife.co.jp/dlri/ldi/report/rp0405.pdf
14This may lead to the ujigami (氏神). There was a custom thata community worship the dead people where lived there. In thiscase, gami(kami) means the accepters’ spilits. See Yanagida(1975).
15
Death of a patient means the end of the patient’s personal life
and, at the same time, the start of life without him or her for thefamily. It raises the significant change into daily life of thefamily, which means a breakdown of the present order. The
family members play a role of recovering the broken order anda role of caring for the dead after a patient died.
12Eubios Journal of Asian and International Bioethics 22 (March 2012)
Summary of three levels structure in Japanese endof- life care
We have started with a desire for dying naturally that
seems to be shared by the opponents and proponents of
ANH. It corresponds the first level of three. Next, in order
to explore what underlies the desire, we overviewed
Japanese ancient views of life and death. By referring to
the concept and original usages of inochi, we saw thatJapanese views of life and death were connected eachother. Under the Shinto tradition, the connection was
conscious but death was regarded to be avoided fromdaily life. Death was the object of fear for ancient people.
Buddhism gave them a possible way to release from thefear. Samurai developed another way to release from it. It
was the mental preparation for death and it wasdepended on self-help. Those considerations formed thethird level. Then, we have reconsidered the concepts of
SOL and QOL based on the Japanese concept of inochi.
They had a different value system of life. The part was
the second level.
Finally let us back to reviews of the different responsesof ANH. Those responses can be interpreted under two
images of dying naturally. It appears that they arecontradicting, but as we have seen they have been
existing in the Japanese tradition.
What the proponents of ANH emphasize can beconsidered as the way of dying naturally which means toleave self to a great and dynamic stream. Self and its
inochi are incorporated into such a stream. It can beconnected with the attitude of resignation. We have noway to escape from death, except to be saved by
Buddha or by taking in a great and dynamic stream. Ourdeath is beyond human power. Therefore, theproponents of ANH may reject withdrawing ANH, once it
is started. For it does not mean the liberation of life withsuffering. The liberation should be realized ultimately by
Buddha or by taking in a great and dynamic stream, notby human power. According to this way of thinking,committing suicide can mean to cut off the connection
with the stream. Such a way may not be said to benatural.
However, it is certain that the attitude of accepting
suicide can be seen in Japanese culture. The opponentsof ANH may support for the positive preparation fordeath. Keeping alive under ANH may be unwilling for thepeople got such a preparation already. We saw theattitude of respecting authentic self in the cases ofseppuku, when samurai chose to die. It meant thatmaintaining life does not always have a priority. Then it iscan be said that people who are dying by themselves
follow the nature they possess within themselves.
Conclusion
In this paper, in order to analyze the three levels
structure in the Japanese end-of-life care, we adopted
the different approach from Asai’s approach. He adopted
the bottom-up approach, from the first level to the second
level, and from the second level to the third level. We
shared the first level with Asai and then adopted the topdown approach, because our purpose was to explore theJapanese principles and concepts which affected theconcrete moral judgments in end-of-life care.

57

The explanation may not be enough to explain thewhole of diverse situation in Japanese end-of-life care.
Especially, we did not consider about the role of family
members of terminal patients. About this point, theeffects from Confusion ethics can be seen in Japaneseculture. Including such appoint, a hypnosis of the thirdlevel was presented will be needed to inspect therelationship with other levels further.

Figure 1: Summary of the three level analysis
References
Asai, Atsushi (2011) “A Question in End-of-life Medicine inJapan: Three Levels Structure Analysis of the Ethics ofProvision of Permanent and Active Artificial Nutrition andHydration for Elderly who Cannot Eat”, Eubios Journal of
Asian and International Bioethics 21, pp. 37-41.
Kato, Shuichi. Lifton, J. Robert and Reich, Michael (1979). Six
Lives Six Death: Portraits from Modern Japan, Yale University
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シュ, R. J. リフトン (1977), 矢島翠訳, 岩波書店)
Morioka, Masahiro (1991). “The Concept of Inochi: A
Philosophical Perspective in the Study of Life”, Japan Review
2, pp-83-115.
Nishida, Koichi (2009). Kodai nihon no shiseikan kara miru
seimei toiu kachi (｢古代日本の生命観から見る生命という価値｣ ),Takahashi, Takao and Kume, Kazuhiko ed. Siemei toiu
kachi- sono honshistu wo tou (『生命という価値―その本質を問う』), Kyushu University Press, pp.62-79.
Sagara, Toru (1984). Nihonjin no seisei kan (the Japanese viewof life and death), Perikansha publishing Inc, Tokyo.
------(1984). Nihonjinn no kokoro(『日本人の心』). University ofTokyo, Tokyo.
Takahashi, Takao (2009). San ga seimeirinri ni katarukoto (「「 産 」 が 生 命 倫 理 に 語 る こ と ‐ 「 生 命 」 の 多 義 性 」 ),Takahashi, Takao and Kume, Kazuhiko ed. Siemei toiu kachisono honshistu wo tou (『生命という価値―その本質を問う』), Kyushu University Press, pp.62-79.
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kento (「日本人高齢者のスピリチュアリティ概念構造の検討」) 川崎医療福祉学会誌, Vol. 16, No.1, pp. 53-66.
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Eubios Journal of Asian and International Bioethics 22 (March 2012)

Yanagida, Kunio (1975). Senzo no hanashi (『先祖の話』),
Chikuma Shobo, Tokyo.

Advance Directives in HongKong: ethical perspectives- Wai Yan Law, Hong Kong
Email: emilylawwy@yahoo.com.hk

Introduction
Discussing death and all related matters is a taboo in
Chinese culture. Some Chinese people believe thattalking about death will increase the likelihood of its
occurrence and that evil spirits will be attracted to haunt
people (Chan, 2000). Nevertheless, this culture ischanging subtly. Since the end of the twentieth century,
both the public and the academics in Hong Kong havedrawn increasing attention to end-of-life care issues(HKSAR, 2005; Hiu et al, 1997; Ip et al, 1998; Leung,
2000; Liu, 2007; Pang et al, 2007). Different disciplines
such as health care, social policy and philosophy attempt
to contribute to the debate on end-of-life care (Chan andChow, 2006; Liu, 2009; Tse and Tao, 2004). One of theissues being discussed is Advance Directives (ADs)(Chan, 2004; Kong and Mok, 2006).
The ADs model form has been introduced by the Law
Reform Commission (LRC) in 2006. It created somepublic and academic debate for one fleeting moment. It
appears that the public confuses the terms ADs witheuthanasia. Another problem is that research related to
end-of-life care in Hong Kong is limited to descriptive
studies of patients, their family as well as the health care
professionals involved (Chiu and Li, 2000; Chiu & Woo,
2004; Gruber et al, 2008; Ip et al, 1998; Leung, 2000;
Lee et al, 2003). Moreover, the interests of professionals
in ADs merely lies in how doctors can be protected fromliability and developing procedures as well as guidelines
on making ADs at institutional level (Kong & Mok, 2006;
Liu, 2005). However, little attention is paid to the ethicaland philosophical aspects of ADs (Chan, 2004).
According to the experiences from other countries suchas the Netherlands and the United States, the ADs in
persons with advanced dementia – for example,
Alzheimer disease- is one of the significant ethical andpractical dilemmas (Black et al, 2009; Gastmans andLepeleire, 2010; Hertogh et al, 2007). In Hong Kong, theend-of-life care treatments decision making for advanced
dementia persons have relied mainly on the surrogatessuch as family members and health care professionals(Pang et al, 2007). However, the surrogates face several
problems in making end-of-life care treatment decisions
such as discerning the patients’ own wish and theinterpretation of the patient’s wishes (Lautrette et al,2008; Pang et al, 2007). Under the LRC frameworks, theADs can be considered as an advance decision making
by the mentally competent adult to retain control in endof-life care treatments if they become mentally
incapacitated in the future such as dementia. ADs areespecially relevant in patients with dementia but it has so
far been overlooked in Hong Kong (Lee et al, 2006).
The aim of this paper is to formulate the ethical andphilosophical arguments regarding ADs in person withadvanced dementia. The method used is literature
review. To retrieve the most relevant literature on ADs
and advanced dementia, a thorough search for relevant
studies was conducted in the databases PubMed, Cinahl,
the Cochrane library, Philosopher’s index and Google
Scholar. The following keywords are used: advancedirectives, living will, health care proxy, advance careplanning, power of attorney, dementia, end-of-life care,
end-of-life decision, do-not-resuscitate, forgoing life
sustaining
treatments,
withdraworwithholding
treatments. Original English-language or Chineselanguage studies were selected.
This paper first reviews the literature in order to provide
a brief overview of caring for patients with dementia andthe introduction of ADs in Hong Kong. After the brief
overview, the potentials and problems of using themodels form ADs in Hong Kong will be evaluated anddiscussed from ethical perspectives. In conclusion, somerecommendations for clinical practice and further
research will be made.
Caring for patients with dementia in Hong Kong
The population in Hong Kong is aging, and more
people now live with the effects of serious chronic
illnesses towards the end of life. The high life expectancy
rate in Hong Kong has been associated with the increaseof the prevalence of older persons with dementia. The
Hong Kong Government estimated that more than 30%of the older persons have cognitive impairments or havesignificant memory complaints (The Census andStatistics Department, 2006). It was estimated by asurvey that more than 17% of the population aged over
70 in Hong Kong suffered from mild or very mild
dementia (Lam et al, 2007).
Dementia is an incurable and progressive diseasecaused by degeneration of the brain cells. Persons withdementia suffer from gradual loss of cognitive functions
and mental abilities as well as swallowing abilities. In the
final stage of dementia, patients are incontinent, andaphasic, totally dependent and even bedridden.
Furthermore, they lose swallowing abilities the capacity
to communicate with others and then subsequent death.
The end-of-life care decision making for patients withadvanceddementia
ischallenging
regardingprognostication (Gastmans, 2010; Pang et al, 2007).
The Hospital Authority (HA), a statutory body to provide
public hospitals and related services in Hong Kong has astandard procedure of end-of-life care decision for
terminally ill patients. The doctors in charge are clinicallyand legally responsible for medical decisions. According
to the Guidelines on life-sustaining treatment in terminallyill patients which was published in 2002, health care
professionals should follow the guidance in making
decisions to withhold or withdraw the life-sustaining
treatments with regards to patient’s wishes and consent
from the families (Hospital Authority, 2002). Moreover,the health care professionals are advised to make ethicaldecision in accordance with the ethical principles –beneficence, non-maleficence, respect for autonomy andjustice. The HA Guidelines state that it is acceptable towithdraw or withhold artificial nutrition and hydration
when death is imminent and inevitable or when amentally competent patient clearly expresses his or her

Eubios Journal of Asian and International Bioethics 22 (March 2012)
own wish. In cases where a mentally incompetent patientin terminally ill without valid ADs, the health care
professionals should reach consensus with the family
members, based on the best interest of the patient
principle. HA concurs that withholding or withdrawing lifesustaining treatment is ethically and legally acceptable
when treatment is futile. However, the concept of futility isblurred and it is considered under both medical
prognostication and value-laden notions. Clinically, there
is no formal procedure for making such decision inadvance except for cardiopulmonary resuscitation.
Withdrawing or withholding tube feeding for advanced
dementia is one of the essential and complex problems in
the end-of-life care decision. Artificial nutrition andhydration are classified as medical treatment while oral
nutrition and hydration are regarded as basic care
(Hospital Authority, 2002). Difficulty in eating is a signalthat the patient has entered the final phase of dementia(Gillick, 2000). In fact, tube feeding can cause more
suffering to the patients who might suffer from clogging oftubes, diarrhea and physical restraint that prevent themfrom pulling out of tubing. Tube feeding may no longer be
providing benefit to the advance dementia patient who isdying and the treatment goal maybe to relieve suffering(Samanta and Samanta, 2006). Geppert et al. reported
that there is lack of evidence to support the practice oftube feeding in caring of advanced dementia patients(Geppert et al, 2010).. Medical practices in Hong Kongare prone to life preservation. Tube feeding for theadvanced dementia patients in the end-of-life care is thecommon practice, in which health care professionals not
only are committed to provide quality care for the patients
but also would be better protected themselves from legal
liability (Pang et al, 2004). Nevertheless, the insertion of
feeding tubes in patients with advanced dementia iscontroversial in the clinical settings. On the other hand,the family members often request hand feeding andwithdraw the tube feeding because of the patient’s
suffering or rejection to the tube (Pang et al, 2007).
The health care professionals and the family members
have to face difficulties in end-of-life care decision ofwhether to withdraw life-sustaining treatment, often
without knowledge of patients’ wills (Chiu & Li, 2000).
Furthermore, there are three main difficulties
encountered by the doctors in reaching consensus withpatient’s family members (Tse, 2005a). Firstly, family
members have unrealistic expectations on the prognosis
and outcomes of treatments. Secondly, the scepticism
about end-of-life care decision as institutional
abandonment driven is also the hurdle in reachingconsensus with family members. Thirdly, in Chinese
cultural beliefs it is a taboo to talk about death related
issues.
ADs in Hong Kong
In order to reduce disputes and minimize theuncertainty faced by health care professionals or family
members about the end-of-life care treatment decision,ADs model forms are promoted in Hong Kong. The moral
principles underpinning ADs are respect for patientautonomy and extend patients’ right to self-determination
to future end-of-life care decisions. It is believed that ADs
offer the persons an alternative to choose death with59

dignity and minimize legal conflicts (Kong and Mok,
2006).
LRC issued its final report on ‘Substitute decisionmaking and ADs in relation to medical treatment’ inAugust 2006, with reference to the legal and health caresystem in Australia, Canada, England and Wales,
Scotland, Singapore and the United States. The LRC
suggested promoting ADs initially by non-legislativemeans. It put forward a model form of ADs which can beused by those wishing to make decisions as to their
future health care. The government agrees with LRC’sview that it would be premature to formulate a legislative
form of ADs. A consultation paper on the introduction of
the concept of ADs in Hong Kong was issued by thegovernment in response to the LRC’s recommendations.
The government consulted the medical and legal
professions as well as the general public on theimplementations of ADs during the consultation period
from 23 December 2009 to 22 March 2010 (Food and
Health Bureau, 2009). Accordingly, the Hong Kong
Government has no intention to actively advocate or
encourage the public to make decision to their end-of-lifecare as it states that this is entirely a personal decision,
to respect individuals’ freedom of making decisions(Legislative Council Paper, 2008-09). The Government
would rather encourage the health care professional andorganizations not only to revise their own guidelines but
also to educate the public on ADs by using theinformation package. The guidelines and procedures forhandling ADs will be formulated at institutional level.
The introduction of ADs by LRC and the government
have created some debates among both the generalpublic and the professionals. For debate among thegeneral public, it appears that the term ADs is mixed up
with euthanasia. For instance, some of the religious
leaders are against ADs because they worry about the
progress towards euthanasia and deontological doctor’s
duty of not to kill (Kung Kao Po. 2006; Law, 2006; Wu,
2006). Mass media narrate the concept of ADs as‘passive euthanasia’ or ‘modified euthanasia’ (HongKong Daily News, 2008; The Sun Newspaper, 2006; Siu,
2010). In other words, Hong Kong people confuse theconcept of ADs with euthanasia, withdrawing or
withholding life-sustaining treatments. On the other hand,
the general public, patients groups and non governmentorganizations have shown concerns about the written
ADs that might limit their end-of-life care treatments or
quality of health care services received in the future. The
responses from general public reflect that ADs might notfacilitate the doctors to reach consensus with the patientsand family members on the end-of-life care decision.
It has been generally acknowledged that the medical
profession’s role is critical in shaping and constraining
health policy in Hong Kong (Gould, 2006). The current
academic discussion about ADs is dominated by the
medical professionals, in which mainly divided into two
aspects. Firstly, the health care professions discuss ADs
under the framework of end-of-life care, which are mainly
the descriptive studies. Secondly, following therecommendations by the government, the doctors
attempt to contribute towards not only criticizing theapplicability of the ADs in Hong Kong but also formulating
the procedures and guidelines in handling ADs (Au-

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Eubios Journal of Asian and International Bioethics 22 (March 2012)

Yeung, 2005; Hui, 2007; Hui, 2008; Kwok, 2006; Tse,
2005; Kong & Mok, 2006).
Other professions also endeavour to participate in theacademics discussion. For instance, the legal validity ofusing a non-legislative model form is challenged and thelegislative status of ADs has recommended from a legal
perspective (Liu, 2005 & 2007). Moreover, from thephilosophical perspective, Ho Mun Chan argues the‘familial’ advance directive that the adult shares decision
making on the ADs with his/her family members isculturally applicable in practice (Chan, 2004). He further
explains that ‘familial’ ADs are not only to solve thephilosophical problem of demented patients’ personal
identity but also to balance the notions of individualautonomy and family involvement in medical decision
making in the Hong Kong context. In other words,
philosophical discussion is one of the crucial notions indealing with the cultural beliefs and practices. It would
thus be of interest and value to learn the ethical andphilosophical perspectives on ADs.
Potentials of ADs in Hong Kong
Although ADs remain a challenge in clinicalimplementation and the theoretical perspectives, ADs arevalued not only to expand the autonomy of the patient in
the future but also to minimize the uncertainty faced by
the surrogates about the end-of-life care decision. From a
psychological perspective, ADs are beneficial because
they reduce anxiety and increase self-respect of thepatients (Brown, 2003). In addition, it also can offer
patients real mental comfort or reassurance, allowing
them to retain control of their end of life health care evenafter they have become incompetent (Gastmans &Lepeleire, 2010).
According to HA guidelines in 2002, health care
professionals are encouraged to consider thesuggestions by Beauchamp and Childress (2001) on
ethical principles, which are respect for autonomy,
beneficence, non-maleficence and justice. The potential
ADs will therefore be analysed under these ethicalprinciples.
Respect for autonomy
In the advance directive debate, respecting a patient’s
autonomy is an important value. ADs are considered as
the counter of the excessive medical paternalism. It
prioritizes the patient’s autonomy while it limits themonopolization of decision making by the medical
professions that might ignore the wishes of the patients.
The individual autonomy is required for respect eventhough it is not an absolute dominion.
Human autonomy should be seen within the network ofa person’s relation and world. The person is best thoughtof as a human agent, a being of this embodied kind, who
acts and interacts in a cultural and historical context inwhich he or she is embedded (Hughes, 2001). The
demented patients are in relation with their own family,
relatives and friends as well as the care providers, healthcare institutions and systems in Hong Kong and theirworld. The Chinese concept of holistic and social
personhood, (regulated by the principle of filial piety andorganized in a social hierarchy), provides distinctive
perspectives in the end-of-life care decision making

particularly in the case of the elderly (Hui, 2004). The
individual is considered as an integral part of the family
and therefore the wills of the family members should take
into consideration and hence decision making belongs to
the family rather than the individual only (Bowman &Singer, 2001). The will of the patient is highly respected
while the consensus is made with the whole family. In
Chinese culture, the patient can be seen as autonomous
person even if he/she gives up the care decision making
to the family members (Fan & Tao, 2004). Therefore,
respect the autonomy of the patient in the Chinesecontext is not only the issue of self-determination but also
the familial determination.
The family and the doctors in fact bear a very heavy
burden to make life and death decision for the demented
patients. ADs do not free the doctors from responsibilities
in making the ultimate end-of-life care choices (Loewy,2010). However, ADs help them make emotionallystressful decisions in difficult circumstances (Hackler,
2004). Given the denial of death in Chinese culture, ADs
help to create a window of opportunity for shared end-oflife care decision making (Hertogh, 2009). Therefore, inthe familial-valued context, Chan (2004) criticises that
individual autonomy is excessively patient-centred so hesuggests that making ADs in Hong Kong should be asharing process by the family members and the patients.
It assists to articulate the will of the patient which upholds
the patients’ autonomy while at the same time the family
members’ wishes are also taken into considerations.
Beneficence and Non malefience
An advance directive is an instrument that serves as abasis of discussion with doctors, other health care
professions and family about end-of-life care treatmentsof the patient with dementia (Loewy, 2004). For thepatients’ best interests, the patient should be wellinformed and make ADs regarding to their own values,
goals, personal and cultural preference as well as the
medical conditions. During the discussion process, it is
not only the patient’s wishes are made known but also
the medical health education about the end-of-life care isgiven to patient and the family members. It might assist
to realistically adjust the expectations on the prognosis
and treatments outcome of the patient and family
members.
According to the principles of beneficence and non
maleficence, the doctors share the responsibilities toguide and educate the patient in selecting options for
medical treatment in order to improve the quality of careto the patients with advance dementia. Withholding orwithdrawing tube feeding in caring patients withadvanced dementia is to avoid prolong suffering by futile
treatments. Therefore, ADs are a platform for health care
professionals to discuss the end-of-life care with thepatient and the family members in advance in order toimprove the health care services standard and patients’quality of life.
Justice
Health care professions should treat all patients
according to what is fair or due to them (HA, 2002). On
the other hand, the patient cannot claim unlimited rights
without regard to the impact on the scarcity of resources.

Eubios Journal of Asian and International Bioethics 22 (March 2012)
Weber (1993) urges that self determination or autonomy
should be viewed from the perspectives of distributive
justice and hence an understanding of a right to demandand get whatever is wanted should be avoided.
Additionally, the health care professionals also share theresponsibilities to assist the better allocation of scareresources in the clinical practices. Therefore, ADs will
promote or forgo the futile treatments and theunnecessary medical expenses will be saved. Moreover,ADs are considered as an education tool for the generalpublic because some of the patients and/or their family
members make absolute health care decisions without
considering the competing right of others or the limited
resources.
Problems of ADs in Hong Kong
Practical problems
Although the introduction of ADs in Hong Kong is still ata budding stage, some foreseeable problems can bearticulated with reference to other countries’ experiences.
ADs have been available in the United States for two
decades but patients in the United States are reluctant tomake plans for a critical situation and draw up ADs(Zimmermann & Rodin, 2004). Available literature showsthat only small numbers of Americans have an advancedirective and that ADs play a limited role in facilitating
harmonious end-of-life care decision making (Tillyard,2007). Messinger-Rapport et al (2009) reiterate that fivereasons might articulate why ADs are less successful
than originally hoped in the United States. First, thedoctors may not know the patient has an advancedirective. Second, the surrogates may not know thepatient’s wishes. It is also a question of whether ADs canreflect the wishes of a person about a certain moment
when it is formulated at an earlier time under different
circumstance. Third, the family members might override
patient’s advance planning because they may disagreewith patient’s decision. Fourth, the doctors may not beable to communicate with each other about a particularpatient’s wish as they may work in different institutions.
Fifth, it is difficult to translate the documents into an
action plan as the different interpretations of medical
terms between the doctors and the patient. In addition,
ADs give little information about the patients’ idea of
quality of life, value and goals (Asselt, 2006). Therefore,
ADs might not help doctors to make the difficult choice of
whether life-sustaining treatments should be withheld or
withdrawn in the best interests of the patient.
Moreover, similar to Hong Kong, a common
assumption of American patients is that having an
advance directive automatically will limit health care
(Loewy, 2004). On the other hand, the government warns
that the health care system is facing major financing
challenges (Hong Kong Food and Health Bureau, 2008).
Although advance directive are not the means foraddressing the issues about high costs of end-of-life careand financing, it is unavoidable for the stakeholders to
associate the medical expense in the end-of-life caredecision process. LRC and the Hong Kong Government
argue that ADs will minimize the disputes and uncertainty
faced by the surrogates. Nevertheless, with reference to
the American experience, the conflicts among health care
workers and the family members might not be ideally61

reduced in the end-of-life care decision for the patientwith ADs.
Cultural beliefs and taboos
Making ADs especially with the elderly is in fact
breaking the taboo of talking about ‘death and dying’ in
the Chinese culture. Although the traditional Chinese
value has been challenged or loosened, the influence ofthe traditional Chinese value is still found in Hong Kong.
For instance, filial piety is not totally forgotten in presentday Hong Kong. It is still upheld by most Hong Kong
people as a value that they should treasure and practicein ways that they find suitable and appropriate. Also
family members might show their filial piety by neverforgoing treatments (Hui, 1999a). Dealing with thecultural taboos or beliefs is one of the essential
challenges in the introduction of ADs.
Moreover, there is a popular saying in Chinese:‘doctors have the heart of parents’, indicating that people
expect doctors to act lovingly as parents do, and accord
them a level of respect commensurate with elders andparents (Hui, 1999b). Furthermore, Chinese patients are
generally quite modest and compliant so it is notuncommon in Hong Kong for doctors to have apaternalistic attitude in their dealings with patients (Chan& Rhind, 1997). Respect for an individual’s right to selfdetermination is a weak notion in Chinese culture. The
life-and-death treatment decisions are to be made by
doctors who are required to seek support andacceptance rather than consent from the patient and\or
the family members in clinical practices (Tao, 2006).
Under such circumstance, the patients and family
members are passive to make clinical end-of-life caredecision. In Spain, two main challenges are identified
from the limited use of ADs, in which are the Spanish
society neglects the concepts related to end-of-life caredecision making and the passive attitude towards clinicaldecision making by the patients (Simon-Lorda et al,2008). The Spanish experience suggests that the
introduction of ADs in Hong Kong would not change thepassive attitudes of the patients to make ADs or advanceplanning on the end-of-life care.
Current Autonomy Vs Precedent Autonomy
In advance directive debate, respecting a person’s
autonomy is highly stressed and hence the problem of
personal identity of the dementia person arises (Kuhse,
1999). It is argued that the demented person is a ‘new’person because he/she is radically different from or is not
psychologically connected to the person who wrote theADs. The view of the person with dementia is one of the
crucial philosophical problems but this notion is lessdiscussed in Hong Kong. The philosophical consideration
is mainly focused on the issue of autonomy (Chan,
2004).
The end-of-life care decisions for people with dementia
have long been intensively debated in the Netherlands
society. It is a very common clinical experience thatpatients with dementia regularly contradict their own ADs(Hertogh, 2005). The surrogates face a dilemma on how
to balance the actual references of the person withdementia against the patient’s earlier opinion laid down ina now forgotten AD. Hertogh et al. (2007) conclude that

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Eubios Journal of Asian and International Bioethics 22 (March 2012)

the Dutch dementia debate raises an urgency of a careful
discussion on the limits of precedent autonomy. It also
raises another important ethical question on how far the
self-determination ought to be respected.
It seems to be well accepted that demented people areunlikely to be capable in making their own end-of-life careplanning or ADs due to progressive cognitive function
deteriorating. If the elderly are not cognitively sound, theirpreferences will be overridden by the surrogates such as
doctors and the family members (Chan & Pang, 2007).
That is to say the autonomy of the patient especially tothe elderly is conditional. On the other hand, it is also afact that despite significant cognitive impairment, mildly
demented patients are able to value their situation andexpress a relatively positive view towards making end-oflife decisions (Lee et al, 2006). In short, the current
autonomy of the demented patient is infrequently
respected while the precedent rational autonomy isvalued. Thus, a valid ethical dilemma faced is how totake account of the current preferences and values ofdemented patients in the ADs or end-of-life care decision
making in order to show respect for the current
autonomy. This falls into the same conclusion with Liu(2005) that the model form of advance directive affirms
the same approach with the HA Guidelines 2002 to deal
with the end-of-life care decision in clinical practice.
However, the model form of ADs would not facilitate toextend the autonomy of the patients with advanced
dementia.
Discussion and Recommendations
The above ethical arguments about the ADs in Hong
Kong should be balanced. Balancing is the process toweigh the different moral values (Beauchamp &Childress, 2001). The potential usefulness of ADs todifferent stakeholders is well recognised. The crucial
underpinning principle of ADs is to respect autonomy andthus provide an avenue for individuals to exercise theirrightofself-determination.
ADs
facilitate
thecommunication among health care professionals andpatients as well as the family members to retrieve a clear
indication of the patient’s wish about end-of-life care.
Furthermore, it is a process for patients with dementia
and family members discuss the end-of-life planning in
advance and have realistic expectations on end-of-lifecare. It also helps the doctors to fulfil their professional
responsibility to patients as they deliver end-of-life caretreatments based on the patient’s will and the principle ofthe best interest. The model form of ADs offers adequate
legal protection to the doctors especially in thewithholding or withdrawal of medical treatments.
Nevertheless, it is necessary that legislation includes
provisions such as to protect doctors from liability when
they act in good faith (Liu, 2005).
On the other hand, predictable problems of using ADs
should be seriously taken into consideration. Recognisingsome of the practical problems in using the ADs, theHong Kong Government proposes two main actions topromote ADs. One of the main actions is to formulate theguidelines and procedures for handling ADs in
consultation with the relevant professional bodies. It is no
doubt that formulating the guidelines or procedures isessential. Nevertheless, some of the essential problems

should be further explored, which anticipates the
successfulness of using ADs.
Although one of the main challenges to introducing
ADs in Hong Kong is the taboo of talking about deathand related issues, cultures and taboos will not change ina short period of time. ADs have provided a platform forthe stakeholders to deal with these sensitive but
important issues. ADs also arouse the general public’s
awareness of the end-of-life treatment and advance careplanning. As the concept of ADs is new to the generalpublic, another main proposed action by the Governmentis to make the concept of ADs accessible to the generalpublic by formulating an information package. The aim offormulating the relevant package is to educate thegeneral public about ADs and the concepts of advancecare planning. The education should not only focus on
the promoting the concepts of ADs and advance careplanning but also extend the scope to the ‘life and deatheducation’. The question then is who are to be theeducators? The government identifies some of the
stakeholders such as health care and legal professionals,
hospitals, organisations providing elderly care and patientgroups. As death is the important and great event of
human life, the humanity in medicine is recommended tointegrate into health care professionals’ academic
training.
The philosophical considerations contribute not only tothe need to revisit the fundamental notion of ADs and therelated issues but also to facilitate the implementation of
ADs in clinical settings. The current interpretation ofautonomy is closely tied to the concepts of self
determination, decision capacity and competence.
Nevertheless, the concepts of the term “autonomy” are a
multifaceted notion. In this paper, the relational
autonomy, current and precedent autonomy are
discussed. Another important facet of autonomy, bodily
autonomy, pays a crucial role to interpret the autonomyof the patients with advance dementia (Dekkers, 2004).
Bodily autonomy is understood as autonomy of the body.
The patients with advance dementia express their wills
by bodily ways. Therefore, the best interest principle
always plays a role even if the patient has an AD.
Which health care setting is the best position to makethe ADs with the patients and/or their family members?
The doctors tend to engage patients and families in
discussions about the end-of-life care only late in thecourse of illness. These practices suggest that thedoctors take ADs as a means to persuade family to forgo
treatments (Fried & Drickamer, 2010). As primary carefocuses on health promotion, the primary care setting isparticularly well-suited to the establishment of ADs(Pugno, 2004). However, the primary health careservices are being dominated by private practitioners inHong Kong (Gauld & Gould, 2002). In order to better
allocation of limited resources, the Government should
distribute more resources in the primary care to promote
the establishment of ADs.
In the end-of-life care of the terminally ill, it is important
to enable the patient to die with dignity (HA, 2002). The
engagement of the patients in the end-of-life caredecision is a way for them to express their views, values
and belief. ADs are considered as a tool to respect the
choice of the patients and hence promote dignified death.

Eubios Journal of Asian and International Bioethics 22 (March 2012)Conclusions
In caring for the patients with dementia, the health care
professional and the family members face dilemmas ofmaking an ethical end-of-life care decision in Hong Kong.
The model form of ADs is introduced in order to respect
the wishes of the patients and shrink the disputes among
the health care professionals as well as the family
members. From ethical perspectives, ADs are launchedregarding the principles of respect for the autonomy andbest interest of the patients. The current academic
debates on ADs in Hong Kong are mainly focused on theimplementation of ADs in the clinical settings while thephilosophical and ethical perspectives of ADs are
neglected.
ADs are studied from the ethical and philosophicalnotions in order to evaluate the foundation potential andproblems of using ADs. ADs are analysed under ethicalprinciples. Self determination of the patients withdementia can be extended and respected while thesurrogates can make an ethical end-of-life care decision
based on the ADs. Furthermore, ADs will facilitate tosave unnecessary medical expense in the end-of-lifecare treatment. On the other hand, the effectiveness of
the ADs in the clinical settings is in doubt with reference
to the other countries’ experience. Promoting ADs in thedeath denial context like Hong Kong, it is not only
breaking the taboos but also facing challenges to change
the public’s attitudes. Additionally, ADs respect theprecedent rational autonomy of the patients withadvanced dementia while the current autonomy and thebodily autonomy are neglected. In balancing botharguments, ADs are valued because the quality of life
and the dignity of the patients are withheld. It is wellrecognized that ADs in a model form rather than alegislative one is a small step towards a more open
environment for such sensitive discussion with thegeneral public in Hong Kong.
This paper attempts to fill the knowledge gap in the
research from the ethical perspectives and to contributeto the ethical notion about ADs. Furthermore, further
research is suggested about the different facets ofautonomy and personal identity of the patients withadvance dementia in Hong Kong. The ethical notion ofadvance care planning in the Chinese context is also a
substantial area in need of further research.
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Eubios Journal of Asian and International Bioethics 22 (March 2012)

Death Anxiety in University
Students- Asst. Prof Selim Kadioğlu MD PhDÇukurova University Faculty of Medicine Department of Historyof medicine and Ethic, Adana, Turkey
Email: selimkad@cu.edu.tr- Asst. Prof Oya Ögenler MD, PhD
Mersin University Faculty of Medicine Department of History of
medicine and Ethic, Mersin, Turkey [corresponding author]
Email: oyaogenler@gmail.com- Asst. Prof Funda Kadioğlu Dt, PhD
Çukurova University Faculty of Medicine Department of Historyof medicine and Ethic, Adana, Turkey
Email: fgkadioglu@cu.edu.tr- Mehmet Ali Sungur PhD Student
Mersin University Faculty of Medicine Department of
Biostatistics and Medical Informatics, Mersin, Turkey
Email: malisungur@yahoo.com

Abstract
Objective: The aims of this study were to evaluate
medical and nursing students’ approaches to death andto determine their effects on the choice of education field.
Method: The Thorson-Powell Death Anxiety Scale,consisting of 25 phrases, was applied to 161 second
grade university students who divided into two groups.
The health group consisted of medical and nursing
students. The control group was composed ofenvironmental engineering, biology, fine arts students.
The data has been computerized; for group comparisonschi-square, Student’s t and two-way ANOVA tests wereused; frequency (percentage) and the mean±standard
deviation were used for summarizing the data.
Results: The death anxiety of women was found to behigher than that of male students in both health andcontrol groups, and this difference is statisticallysignificant (p<0.05). The death anxiety of the healthgroup (52.60) was slightly higher than the control group(49.69), but this difference was not statistically significant(p>0.05).
Conclusion: Higher death anxiety may affect the choiceof some members of the health profession but there
appears to be no relationship between death anxiety andchoosing the profession.
Key words: Medical ethics, Medical education, Deathanxiety, Death anxiety scale
Introduction
Death, besides being a subject of clinical medicine
oriented towards the attempts to delay or postpone it, isalso a case discussed in the agenda of bioethics within
the framework of such notions as euthanasia, dying with1
dignity etc. The relation between death-medicine does
not merely consist of direct connections; but eachphilosophical, social, psychic, cultural, legal and otherdimension of death has affects on the intellectual
2,3
substructure of medicine.
By nature, professions of health have a close relation
with death; the ones who select these professions get
acquainted with this relation during their training and start
4,5,6
to experience witnessing death.
It is strongly possiblethat this close encounter will inevitably affect death65

anxiety levels, death-related thoughts and behaviors
4towards fatal diseases of the trainees. On the other hand
it might be alleged that the ones who consciously selectthese professions which are based on the fight against
death already have a special interest for death or may
have anxieties-obsessions with death itself. Based onthese deductions, many studies have been conducted on
the death anxiety among nursing and medicine school
5,6,7,8
students.
A set of diversified thesis may be put forward
concerning the relation between choice of healthprofession and death anxiety. In this respect it is feasible
to think that the ones with high levels of death anxiety
select health professions to search for a fight against
death or conversely the ones with low levels of deathanxiety do not hesitate to select these professions thathave a high probability of facing death. The third
possibility argues that there is no relation at all between
the choice of profession and death anxiety.
The research objective of our study is to make adeduction concerning the position of death anxiety inselecting health professions by detecting death-oriented
personal attitudes of a group of nursing and medicine
school sophomores’ via applying a standard deathanxiety scale.
Methods
The study was planned as a cross-sectional type andconducted between January-May 2007. The researchhas been carried out among 187 volunteering students
studying at five different departments of Mersin University
but the evaluation has been made through 161 students
who answered all of the questions. The rest of volunteers
were excluded as they did not answer all of thequestions.
In this research where students from school of
medicine and college of nursing constituted the test
group; considering the criteria of familiarity with life notion
and human body, the control group was selected fromenvironmental engineering, biology and faculty of finearts students.
The research utilized the Thorson-Powell Death
Anxiety Scale (DAS), which is a data gathering tool usedby different disciplines to detect death anxiety levels of
dissimilar groups. The scale’s Turkish adapted version
has Cronbach’s alpha coefficient () 0.84 and reliability
coefficient 0.73; thus is valid and reliable as a
9,10measurement tool.
Cronbach’s alpha coefficient ()scale was calculated as 0.87 in our study.
The scale includes 17 positive and 8 negative - 25
statements in total; the participants have been asked toindicate their views for each question by using the 5-point
Likert format (I completely agree; I agree; I am not sure; Idisagree; I completely disagree ). Accordingly the
choices have scores between 0 and 4 and theparticipants are able to reach a total score between 0
and 100. The higher total score indicates the higher level9of anxiety.
In addition to detecting overall anxiety level, ThorsonPowell death anxiety scale measures the levels in four
sub-types of anxiety. These anxiety sub-types are related
to loss of physical and mental functions, ambiguity of

66

Eubios Journal of Asian and International Bioethics 22 (March 2012)

after-life, decay and spoiling of the dead body,
10
undergoing pain and agony during death.
In our research, the data obtained via scale has been
computerized; for group comparisons chi-square,
Student’s t and two-way ANOVA tests were used;frequency (percentage) and the mean±standard deviation
were used for summarizing the data. In the evaluation ofscale’s scores multivariate analysis methods were notused since the subgroups were selected from the ones
determined by factor analysis and that has no correlation
between each other. Data was analyzed using thestatistical package SPSS v.11.5 for Windows. The pvalues less than 0.05 were regarded as significant.
Results
Of 161 participants where evaluation has been made,78 (61 women, 17 men) are from health group and 83 (39women, 44 men) are from control group. The averageage of students was 21.62 years (age range 18-36).
In general, the average DAS score of all students was
51.10. DAS score average of health group is 52.60,
control group’s is 49.69 and there was no statisticallysignificant difference between both (p=0.268). A
comparison between genders reveals that women havehigher DAS score average than men (55.20 to 44.38).
The difference between females and males was
statistically significant (p<0.05).
From analysis of the death anxiety scale with respect togender and group, it has been detected that between
women in health group and women in control group as
well as men in health and control groups, there is nodifference in terms of average DAS score (p>0.05).
Distribution of health and control groups with respect togender and death anxiety levels and numbers ofparticipants in groups are given in Table 1.
When the death anxiety sub type scores are evaluatedby comparing health and control groups, in anxieties
such as ambiguity of after-life, decay and spoiling of deadbody, undergoing pain and agony during death thescores obtained by the health group are higher than thecontrol group. Amongst all three sub-types there is not a
statistically significant difference between groups(p<0.05). In the anxiety of losing physical and mental
functions, the anxiety level of control group is higher
than health group and among the groups there is no
statistically significant difference (p>0.05). Distribution ofanxiety sub-type score average affecting death anxiety inhealth and control groups is illustrated in Table 2.
Since the number of statements about anxiety subtypes is not equal, in order to compare them with eachother, their score averages have been taken from 100 as
a common denominator. Following this conversion withinall participants, the descending order of average score is(1) undergoing pain and agony during death, (2)ambiguity of after-life, (3) decay and spoiling of deadbody, (4) loss of physical and mental functions. The order
is in the same for health group and control group.
Sequence of anxiety sub-types’ score averages withrespect to scores they receive from participants is shownin Table 3.
In terms of score averages amongst overall students,
the differences are statistically significant (p<0.05)
between anxieties of decay and spoiling of dead bodyand loss of physical and mental functions, ambiguity ofafter-life and undergoing, pain and agony during death.
In the health group, sub-types that have statisticallysignificant differences are: undergoing pain and agonyduring death and loss of physical and mental functions
and decay and spoiling of dead body (p<0.05). In control
group sub-types that have statistically significant
differences are loss of physical functions, ambiguity ofafter-life and pain and agony during death (p<0,05).
Discussion
The death anxiety score averages of our participants
indicate that they have mid-level anxiety and the anxiety
level is significantly higher in women than men. This
general profile is, to a large extent, parallel to the findings
obtained from the researches conducted amongst
university students in Turkey by using both identical anddifferent death anxiety scales.
Within the scope of studies conducted in Turkey via
Thorson-Powell scale, the average score of students
from education, fine arts and religious studies faculties inAtatürk University (Turkey) is 52.89, is rather close to the9general average obtained in our study. In anotherresearch executed in Ankara University Faculty of
Educational Sciences (Turkey), lower anxiety levels havebeen detected; score average of students from computerteaching technologies department is 43.31 and11
counseling and guidance department is 48.58.
In a research carried out in 9 Eylül University (Turkey)
by applying a different scale, among students from eightfaculties (religious studies, law, fine arts, economics andadministrative sciences, education, civil engineering,mining engineering, medicine) no statistically significant
12
difference has been detected just like this research.
Civil engineering faculty students were the group with thehighest score average and school of medicine was
12
placed in the fifth order in this grading.
At this point, based on the limited data, considering the
low level of anxiety of freshman students in medicine andnursing schools, it is possible to argue that high level ofdeath anxiety did not play a key role in their choices ofhealth professions. However while making such anevaluation it would be proper to consider the generalknowledge that families and the score students receive atuniversity student selection exam are more influential
than their personal features and interests. Thisconsideration also accounts for the reason why ingeneral there is not a distinctive difference among
students from different departments.
In the United States, in research conducted by Thorson
and Powell at the end of 1980s among freshman
students from two different medicine schools, DAS score
7,13
averages was found as 43.5 and 47.5.
In the firststudy a control group was included as well. Between thisgroup’s average score 47.49 and scores of students frommedicine school, a statistically significant difference was
detected indicating the low level of anxiety among
7,13
medical students.
The findings of that research are incompatible with ourown research results. Score averages detected byThorson and Powell are lower than both our participants’scores and the control group as well in the first study.

Table 1. Distribution of health and control groups with respect to gender and death anxiety levels
Health group
Mean± SD

Control groupmean± SD

55.26±15.84 N=61

55.10±15.76 N=39

P*

Both of groups
mean± SD

0.961
Women

55.20±15.73

N=100

Men
43.06±16.25 N=1744.89±16.12 N=440.694
44.38±16.04 N=61
P**
0.011
0.005
0.000
Total
52.60±16.62 N=78
49.69±16.67 N=83
0.268
51.10±16.65 N=161
P* the differences are statistically significant (p<0.05) between health group and control group
P** the differences are statistically significant (p<0.05) between women and men
Table 2. Distribution of anxiety sub-type score means affecting death anxiety in health and control groups
Health group
Control groupp
Total± SD± SD± SD
Loss of physical and mental
9.39±5.60
9.04±5.37
9.71±5.82
0.45
functions
0.001
12.08±4.30
Ambiguity of after-life
13.23±3.96
11.00±4.35
6.71±4.71
Decay and spoiling of dead body
7.18±5.01
6.28±4.40
0.23
Undergoing pain and agony during
10.53±2.95
10.69±3.16
10.39±2.74
0.22
death

Table 3. Sequence of anxiety sub-types’ score means with respect to scores
Health group
Control group
W
± SD

M
± SD

Total
± SD

W
± SD

M
± SD

Undergoing
pain andagony during
death

70.49
±
15.56

53.67
±
27.15

66.82
±
19.77

69.39
±
14.39

Ambiguity ofafter-life

69.18
±
20.00

55.29
±
15.04

66.15
±
19.80

48.36
±
31.55

32.35
±
27.88

33.95
±
18.73

26.26
±
20.24

Decay andspoiling ofdead body
Loss ofphysical andmentalfunctions

Total

P*

Total±
SD

W
± SD

M
±SD

P**

Total±
SD

60.93
±
18.58

0.51
2

34.68
±
20.79

70.06
±
15.05

58.91
±
21.33

0.000

65.83
±
18.44

61.02
±
21.70

49.65
±
20.66

0.00
1

55.00
±
21.79

66.00
±
20.96

51.22
±
19.31

0.000

60.40
±
21.52

44.87
±
31.33

48.23
±
29.38

31.25
±
23.34

0.22
6

39.23
±
27.54

48.31
±
30.57

31.55
±
24.45

0.000

41.96
±
29.48

32.28
±
19.20

38.00
±
20.97

31.73
±
20.42

0.44
9

34.68
±
20.79

35.53
±
19.63

30.21
±
20.35

0.102

33.51
±
20.01

P* the differences are statistically significant (p<0.05) between health group and control group
P** all students in general, the differences are statistically significant (p<0.05)
W= Women, M= Men, SD= Standard Deviation
An approach that can interpret this incompatibility is
focusing on time and cultural difference. Anotherapproach may argue that this incompatibility is anindication of the absence of any relationship between
choice of profession and death anxiety.
In our study in both health and control groups DAS
score averages of women are higher than men. This highlevel is valid not only for general score average but for all
anxiety sub-types’ score averages as well. The findingsof significant relations between death anxiety and gendervariable, the high scores of women were also obtained in
the research conducted in Ankara, (Eylül and Atatürk
9,11,12
Universities, Turkey) at different periods of time.
In
studies composed of non-student groups, death anxiety
8,14,15,16,17,18
of women were generally higher.
However,
15,17
there are also studies not revealing such findings.
The relative lowness of male participants’ scores canbe bound to the facts that human life is biologically andculturally much closer to death and having experiencessuch approaching and facing death can diminish theeffect of death anxiety. A study which compares deathanxiety levels of people from professions with low-deathrisks in Turkey such physiologists, accountants,
classroom teachers and professions with high-death risks
such as police officers, pilots and firemen, the finding
indicating that people having high-death risk professions
have lower DAS scores supports the final argument as
14
well.
The evaluation made in the above mentioned researchargues that professional life may have an effect on deathanxiety level; however, death anxiety is not a factor
14
determining choice of profession. On the other hand, ina philosophical evaluation it is asserted that deathanxiety which is shaped by cultural and educational
19
elements plays part in choice of profession. In thisstudy which focuses on death fear and the ways to cope

68

Eubios Journal of Asian and International Bioethics 22 (March 2012)

with it, it is stated that death anxiety level is expected tobe high in health professionals and the research findingsof death anxiety in medical students increases
19throughout senior classes is asserted.
Among the different aspects of death, undergoing pain
and agony during death was the biggest concern of theparticipants in both health and control groups. In a study
conducted via a different DAS, it has been seen thatstudents from Istanbul University Faculty of Medicine(Turkey) likewise stated that they feared most from
20
undergoing pain while dying. It is possible to argue thatsince ever-growing resources of modern medicine can
extend terminal period of life and this period issometimes painful and hopeful, this sub-type of anxiety
precedes the others in a vast majority of public. It is also
possible to deduce that due to their anxieties concerning
pain during death, the participants may have selected
profession of medicine, which on the whole fights against
pain.
Within the context of comparing anxiety sub-types, thefact that ambiguity of after-life also received a high scorein addition to anxiety of pain during death may be basedon the deduction that any type of ambiguity in generalacts as a source of anxiety. Belief in the after-life is aneffective medium in relieving fear of death and achieving
21,22
the desire for immortality.
Feeling less anxious about
the decay of dead body and loss of physical and mental
functions can be indirectly attached to the deduction that
belief in after-life is strong and prevalent.
Conclusion
In this study which has been conducted among alimited number of participants from two groups, healthand control, death anxiety levels of participants havebeen determined both as a whole and as sub-types anda comparison has been made between groups andgenders. Within the scale of all participants, deathanxiety level is medium and it is higher in womencompared to men and greater in health group compared
to control group. As evaluated with respect to anxiety
sub-types, it surfaces that suffering while dying and what
to see after death take front stage whereas not muchanxiety is felt in terms of the fate of dead body and lossof vital functions.
Once evaluated as a whole and compared with otherliterature, our research findings are in line with the results
obtained from studies conducted among similar groups.
Anxiety level of health group is lower than control groupand majority of sub-types. The insignificant difference
can be interpreted in both ways; high level of deathanxiety motivates towards health professions or there is
no relation at all between anxiety level and choice ofprofession.
The studies aiming to identify health professionals withall their different aspects, including the motives in theirprofessional choice, goes beyond forming a unique store
of knowledge and acts as an indirect contributor toproviding more effective and beneficial health services.
On the other hand the fact that death, which is one of thebasic concepts of medicine, has a position with extraclinical insights in the agenda-mind of prospective healthprofessionals can be seen as an effective tool forforming-developing medico-social sensitivity within them.

These two deductions are the points our study originatedfrom. Our suggestion is that from this point forth, similar
studies to be conducted and knowledge store on thisissue to be extended.
References
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3. Kubler-Ross E. On Death and Dying. İstanbul: BZD Press,
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CA. Detached Concern and Death Anxiety of first year
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Population Tabula Rasa 2001; 1 (1): 43-55.
10. Yıldız M. A Study on the relationship between religiosity anddeath anxiety. İzmir: Dokuz Eylül Universty, Instıtute Of
Socıal Scıences PhD thesis, 1998.
11. Tanhan F, Arı F. The Meanıng Unıversıty Students Gıve To
Death And Death Anxıety Levels Accordıng To Theır
Department Universty of Yüzüncü Yıl, Journal of Facultyof Education, 2006; 3 (2): 44-55.
12. Yıldız M. Death anxiety and godlıness. İzmir: Birleşik Press,
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13. Powel FC, Thorson JA, Kara G, Uhl HSM. Stability of
medical students’ attidutes toward aging and death. The
Journal of Psychology 1990; 124 (3) 339-342
14. Eke S. Compare death anxieties of the employers in
different occupations İstanbul: Marmara Universty Institute of
Educational Sciences Msc Thesis, 2003.p 46-57
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Eubios Journal of Asian and International Bioethics 22 (March 2012)İstanbul: İstanbul University Instıtues of Health Sciences Msc
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Bioethics in the Islamic Republicof Iran- Nader Ghotbi, Ph.D.
Ritsumeikan Asia Pacific University, 1-1 Jumonjibaru, Beppu
City, Oita 874-8577, Japan
Email: nader@apu.ac.jp

Introduction
This is a research report on the three layer structure ofbioethical decision-making in the Islamic Republic of Iran.
This report has been prepared based on an investigationon the religious and ethical system of beliefs which isdominant in contemporary Iran (1980~now).
The three layer structure in this report refers to:
1The basic ethical concepts, including ethicalrdtheories and religious beliefs, as the 3 level.
nd2The bioethical principles and laws, as the 2level , and3The decisions made on bioethical issues instmedicine, as the 1 level.
The bioethical issues under investigation are:aThe end of life care,bReproductive medicine, andcOrgan transplantation;
The report will focus on each group of issues according
to a three-year schedule of annual reports. Thus,
following the introduction and a background section, weshall discuss the end of life care, according to the work
schedule for the first year.
Bioethical decision-making in the Islamic Republic of
Iran has a complex and unique structure in many
perspectives. Readers would first need to become
familiar with the overall culture, religion and legal practicein the Islamic Republic of Iran before the discussion ofbioethical issues in medical practice in Iran. Therefore abackground section is provided first as a summary of theneeded information, and then the basic religious andrd
ethical beliefs and theories (3 level) in the Islamic
Republic of Iran will be briefly explained; these represent
a quite unique system in Asia and may not be widely
known among bioethicists even those in other Islamicrdcountries. Moreover, the 3 level concepts have a major
influence on the delineation of the other two levels and agood understanding of our discussion depends onrdfamiliarity with the broader concepts at the 3 level incontemporary Iran.
Background
The theocratic constitution of the Islamic Republic of
Iran was approved in December 1979. Accordingly, the“Supreme Leader” is the legally recognized andlegitimate clergy (faqih mojtahed) and ultimately
responsible for the delineation as well as supervision
over the general policies of the nation and has full power69

to assure all bodies including the legislative parliament,
the judiciary system and the executive government are
following the Shi’a Islamic rule.
The current population (2011) of the Islamic Republicof Iran is about 75 million, 89% of which are Shi’aMuslims, 9% are Sunni Muslims, and 2% are Zoroastrian,Jewish, and Christian. There is another minority of Baha’ibut their religion has not been accepted as legitimate by
the current law.
The Shi’a religion has an overwhelming influence over
all aspects of life in the Islamic Republic of Iran, including
law and ethics. The followers of Shi’a in Iran consider
themselves the “followers” of Ali, the first male convert toIslam, who was the cousin and son-in-law to the Islamic
prophet Mohammad. Shi’a essentially means “follower” inArabic. Shi’a is based first on the teachings of the Quran,
the holy book of all Muslims, and second on the“messages” of the prophet of Islam, Mohammad, as well
as of Ali and other Imams who were his descendents,
carried through “hadith”.
Shi’a favors the “hadith” attributed to Mohammad andImams and credited to the Prophet's family and close
associates, in contrast to the Sunni traditions which arelargely narrated by the Prophet Mohammad's
companions, whom Sunnis consider as trustworthy.
Therefore almost all religious, ethical, political and otherdecisions in the Islamic Republic of Iran ultimately
depend on the interpretations of the widely approved
clergymen (faqih mojtahed) from Islam, which ultimately
falls on the Supreme Leader’s jurisdiction. The decrees
and decisions made by the Supreme Leader can be thesource for interpretation of religious and ethical decisionmaking by all authorities in the Islamic Republic of Iran.
rd

The 3 level; basic ethical concepts, ethical theories
and religious beliefs
rd
The fundamental question at the 3 level to answer isabout the underlying ethical philosophy, whether it isdeontological, focused on actions, or teleological,
focused on consequences. Most readers might besurprised to know that generally Islam and especially
Shi’a are based on a third category of moral thinking
which is mainly based on prima facie obligations similar
to the views of the British philosopher W.D. Ross (18771971). Also interestingly, the consequences of actions,especially those with a public impact, may receive
considerable attention, though they are not viewed in autilitarian perspective. Let me explain the two basic
theories in more detail.
Ethics in Islam is not purely deontological. In Islam,actions are not simply divided into right and wrong; each
person at any moment may have a number of obligations
some of which are more important than others. A Muslim
may decide to perform various actions he is obliged to,and to refrain from others that are to be avoided, basedon a proper ranking of those obligations.
There are various ranks for the varied obligations a
Muslim is bound to do, or “not” to do (to refrain fromdoing). Generally speaking, from a religious/ethicalstandpoint all actions may be basically classified into five
broad ranks as the following:
1- Wajeb (“fariza”) refers to obligatory actions whichmust be done, when possible.

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2- Mostahab refers to actions that had better be done,
but mostly are not obligatory.
3- Mobah refers to neutral actions with a neutral ethicalstatus meaning that there may be no obligation or duty to
do or to refrain from doing those actions.
4- Makruh refers to actions that had better be avoided
but are not fully prohibited.
5- Haram refers to prohibited actions which must be
avoided, if possible.
This classification is only a general guideline for overall
decision-making. Please notice that actions considered“mostahab” are “right” actions which one may still not do,
and actions considered “makruh” are relatively “wrong”
actions which one may still do. The category of “mobah”
actions is not such an inert one either; commonly itsignifies that the judgment to do or not to do an action isleft to the person because no moral obligations will
follow. An example would be the obligation to tell thetruth to a non-believer.
Also, under given circumstances, some actions thatbelong to one certain category may move to othercategories. For instance, eating pork in Islam is generally
well recognized as forbidden (“haram”) but in the casethat the life of a Muslim depends on eating pork, forexample when no other food is available and he may
starve to death, it may be OK (“mobah”) or evenobligatory (“wajeb”) to eat pork at an amount needed tosustain life.
At any given time, a Muslim may be under more than
one obligation and sometimes these obligations may bein conflict. There may be instances when “wajeb”
obligations are in conflict with each other. For example, aMuslim must obey parents and must obey the religious
directions too; what if they are opposite to one another?
That is why in difficult situations, a Muslim may ask for a“decree” to resolve such conflicts. A decree in Shi’acomes from a Shi’a clergy who has studied extensivelyndthe law of Shari’a (principles at the 2 level) and knows
how to rank the various obligations depending on thecircumstances and specifics of the situation (issues of thest
1 level). What a Muslim should do depends on thecircumstances and the relative importance of various
obligations on him. As depicted here, actions are judged
ethical/unethical based on the circumstances surrounding
them. Most of the moral obligations are not absolute, as
opposed to the Kantian ethics, and exceptions areallowed depending on the circumstances.
The following verses in Quran support this view:
Quran 9:3: "Allah and His Messenger dissolve
obligations."
Quran 66:2: "Allah has already sanctioned for you thedissolution of your vows."
Meanwhile, it cannot be said that Islam follows autilitarian view in bioethics. In Quran, it says: Quran 5:32,"...We ordained for the Children of Israel that if any one
slew a person - unless it be for murder or for spreadingmischief in the land - it would be as if he slew the whole
people. And if anyone saved a life, it would be as if hesaved the life of the whole people...."rd
The other significant issue at the 3 level is thecontroversy over universal human dignity vs. a higher
ethical status for Muslims over non-Muslims. Quranregards monotheist religions highly and refers to theirtexts with a lot of respect. These include Christianity,
Judaism and probably Zoroastrianism. Quran defines
Islam as “surrendering oneself to God” and in this way
does not differentiate between the religion that
Muhammad brought and those monotheist religions
before him. The following verse refers to this fact, andalso that other (polytheist) religions would never be
accepted by the God, Quran 3:85: “If anyone desires a
religion other than Islam, never will it be accepted of him
and in the Hereafter he will be in the ranks of those whoare losers."
Unfortunately, some readers have interpreted thisverse to mean that followers of any religion other thanIslam will not be accepted by the God. In this case,obligations that a Muslim has towards another Muslim,
such as not to lie to them, may not hold as strongly to
non-Muslims especially those without a recognized
religion. However, a lack of support for universal humandignity may still cause few problems in Iran. The reason
is that in the Islamic Republic of Iran, everyone must be
formally registered as belonging to one of the recognized
religions: Shi’a Islam, Sunni Islam, Judaism, Christianity,
and Zoroastrian which are the religions recognized by thecurrent Iranian law. The only possible exception is theminority of Baha’i who is not recognized in law and its
followers may be discriminated against if identified assuch. Fortunately, there are very few situations inhealthcare that such a distinction may happen.
It is difficult to make a general statement on thestandpoint of Islam on universal human dignity andhuman rights. It may be helpful to note that a person’s“rights” may be translated into “duties” or “obligations” onothers to treat that person in a certain way. Thus Muslims
may not be obliged by the same duties towards nonMuslims, as they are towards fellow Muslims. An actionthat is forbidden (haram) towards a Muslim may be “notrecommended” (makruh) or just OK (mobah) towards a
non-Muslim, and an action that is obligatory (wajeb)
towards a Muslim may be “recommended” (mustahab) or“OK” (mobah) towards a non-Muslim. Accordingly,
human rights may be looked upon in the perspective of“duties” of an individual Muslim (or the Islamic state)
towards other individuals, and not their “rights”, as inWestern schools of ethics.
nd

The 2 level, biomedical principles and laws
The Islamic methodology for bioethical decision-making
is based on an important principle of “facilitation” or“”circumventing of hardship”, which is derived from a
directive in Quran:
Quran 2:185: “God intends facilitation for you and does
not want to put you in hardship”.
This verse forms the principle for “circumventing ofhardship” and is further supported by hadith which says,“The best of your law is that which brings ease to thepeople”. This principle forms the basis for a fundamental
rule which says: “hardship necessitates relief”.
Another important tradition and law in Islamic bioethics
is that: “no harm” should be inflicted or reciprocated. A
different way of saying this principle is that: “harm must
be rejected”.
One may conclude that harm has no legitimacy inIslam; the prophet’s statement explicitly forbids andEubios Journal of Asian and International Bioethics 22 (March 2012)
removes harm from any consideration. Following thisstatement, many laws have been set up to provide
protection from harm in all aspects of human interaction,
especially where one person’s action may cause harm toanother (as opposed to self-harm).
However, harm is relative to the person who
experiences it. What appears to be wrong prima facie
and is regarded by one party as a harmful act may not be
considered wrong or unjustified by another. Therefore itis the human experience and the “situation” that clarify
the matter of harm. In any case, law requires us to follow
a decision that leads to “the least amount of harm” anddamage to one’s total well-being.
In Islam, the statement of “no harm, no harassment” (lazarar wa la zirar fi islam) forms the main principle for nonmaleficence in medical ethics; for social relations andtransactions, the statement of “protection against distressand constriction” (al-usr wa al-haraj) forms the underlying
principle.
Many Islamic ethicists raise the point that Islamicprinciples in bioethics do not follow the priority ranking
that is observed for the principles of Western bioethics,
namely respect for autonomy, non-maleficence,
beneficence, and justice. For instance, as opposed to thedominant principle of autonomy in Western bioethics,
there is a principle of consultation (shoura) in Islam whichis the dominant feature of Islamic communication ethics.
Also, to balance the likely benefits and harms to society
vs. the individual, the principle of proportionality(tanasub) between individual and social interests of thecommunity may be applied.
In Islam, preventing harm has “priority” over promoting
good; this kind of ranking priorities principle may be usedin the analysis of harm vs. benefit when for example, a
medical procedure prolongs the life of a terminally illpatient without advancing a long-term cure. It also allows
for choosing among the treatment options when theassociated benefits incur different costs and risks topatients “and” their families.
A general principle underlying a lot of bioethicaldecision-making in Islam is the principle of “publicgood” (maslahat). The usage of the term maslahat(public good) can refer to actions that are approved bycommunity members as “reasonable” because of either
promoting good or protecting against harm; it also canrefer to actions that usually agree with what reasonablepeople do.
There are three broad categories of issues that may fallunder the general classification of “public good” in Islam:
1Primary or essential needs (al-zaruriat): Religion,
life, reason, lineage and property form the essentials thatneed to be protected as essential public goods.
2General needs (al-hajiyat): These include
religious duties (ibadat), everyday life situations (adat),
interpersonal relationships (muamalat), and the penal
code (jinayat). For example, a sick person or a traveler is
exempt from certain obligations while sick or in travel (lifesituations); also transactions which are beneficial toadvancement of one’s life are thus allowed (interpersonal
relationships).
3Secondary needs (al-tahsinat): These include
supererogatory or “noble virtues” which may be regarded
as praiseworthy but do not belong to the primary and71

general group of needs. Saving human life by organ
donation would be categorized under this group.
The role of reason and wisdom in ethical decisionmaking is also very important, especially in Shi’a; anagent may use one’s reason and wisdom to apply moral
judgments to the particular situations that come along.
Right and wrong are “objective” qualities that can bediscerned through reason and wisdom, and therefore an
agent is enabled to “reject probable harm” (daf’ al-zarar
al-mohtamal). The acceptance of moral “reasoning” inIslam is based on the existence of innate dispositions(fitra) in humankind which are endowed by the creator;
humans can thus evaluate and judge the moral aspectsof their actions.
To provide solutions to new problems that may emerge
in society on an everyday basis, “analogical reasoning”(qiyas), sound opinion (ra’y), efforts to promote the goodof the people (istislah), the selection of the “mostbeneficial” of several rulings (istihsan), conventions andcustoms of the region (urf), and other forms of reasoning
may be used.
One of the classical juridical traditions in Islam isinstituting good (amr bi al-maruf) and preventing evil(nahy an al-munkar); this tradition requires Muslims toinquire about the reasons behind ethical decisions thatare made for the institution of the “public good” andprevention of public corruption (mafsada).
Now we can turn to the end of life care in the Islamic
Republic of Iran and examine how these principles andlaws are applied to the various situations that arecommonly seen in medical ethics.
st

The 1 level; end-of-life care in the Islamic Republicof IranEnd-of-life care issues are some of the more difficult
challenges in medical ethics. Ethical decision-making incases of euthanasia, physician-assisted suicide, do notresuscitate (DNR) orders, withholding or withdrawing
futile treatments, advance directives in healthcare, andconsent are some of the common topics under debate inthis area.
We can summarize the Islamic ruling over the main
issues in end-of-life care as follows:
1Life is sacred, & death can only be decided by
God; therefore deliberate euthanasia is prohibited.
2Suffering pain may be a form of a spiritual test ortrial; therefore freedom of pain is not an acceptableexcuse for ending one’s life, and active euthanasia isprohibited.
3However, undue suffering is not acceptable inIslam either; therefore if treatment to relieve pain &suffering does not intend death but death is somehow
hastened in the process, it is still acceptable to attempt torelieve pain; palliative care is legitimate.
4Man is not the owner but only a steward of his
body; therefore to reject treatment by a patient may be
sinful. Thus a patient has an obligation to seek treatment,
and should not refuse or reject treatment that isrecommended by the physician. Therefore, the autonomy
of a patient to reject treatment is limited.
5However, death is a divine plan and a transition
to afterlife; therefore futile treatments to delay death are

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not acceptable especially when they may financiallyconstrain the family of the patient or the community.
Generally in Islam, death is considered as a departurefrom one state of existence to the next. Death is a part ofthe divine plan and as such should be accepted withpeace of mind. Islam teaches that a human’s life on earth
is only a test and a good Muslim should endower to reap
the benefits of following the God’s teachings duringhis/her temporary life on Earth for an eternal life inheaven. A Muslim does not resist death or fight to avoid it
against the will of God, but rather accepts it as part of thedivine plan. Muslims are encouraged to reflect on death
frequently and expect it at any moment. Not even theprophet would attempt to avoid death if it came.
The Quran says: Quran 3:185: "No soul can die except
by God's permission."
Quran 32:11: "The angel of death, who has been put incharge of you, shall cause you to die, then to your Lord
you will be returned.”
Quran 67:1-2: "Blessed be the God who has thedominion in his hands and has power over all things. He
who created death and life, he may test which of you are
best in deed, and He is exalted in might, oft-forgiving."
Life and death are in the hands of the God, and not forhumans to decide. Deliberate euthanasia is therefore
prohibited in Islam. However, undue suffering is not
acceptable in Islam either and if in the process ofproviding adequate analgesia death is hastened, it still
may be permitted to provide relief. What is important isthat the primary intent should not be to hasten death, but
to relieve the pain and suffering.
In Islam, life is sacred because God is its origin and its
destiny. The sanctity of human life and the belief in thatdeath does not happen except by God’s permission,
have been stated in Quran:
Quran 3:145: “it is not given to any soul to die, but withthe permission of God at an appointed time”.
Quran 6:151: “Do not take life which God has madesacred except in the course of Justice”.
Quran 5-32: “…whoever slays a soul, unless it be formanslaughter or for mischief in the land, it is as though
he slew mankind…”.
The saving of a life is also considered as having highmerits in Islam. Therefore, healthcare providers must
make any reasonable effort they can to prevent
premature death.
Muslim jurists from different schools have ruled thatonce invasive treatment has been started to save the lifeof a patient, life-saving equipment cannot be turned off
unless the physicians are certain about the inevitability ofdeath. However, the Islamic belief is that death is an
inseparable part of human existence, and thus, treatment
does not have to be provided if it merely prolongs the
final stages of a terminal illness but cannot treat the lifethreatening condition.
Although the primary obligation of a Muslim doctor is toprovide care and alleviate pain, it must be rememberedthat pain can be a form of test or trial, to verify abeliever’s spiritual state: Quran 2:153–57: “O all you whobelieve, seek assistance through patience and prayer;
surely God is with the patient . . . Surely we will try you
with something of fear and hunger, and diminution of
goods and lives and fruits; yet give good tidings to thepatient who, when a misfortune befalls them, say, ‘Surely
we belong to God, and to him we return’; upon those rest
blessings and mercy from their Lord, and those; they are
the truly guided”.
Quran 21:35: “Every soul shall have a taste of death:and we test you by evil and by good by way of trial, to us
you must return”.
Therefore, pain may be an instrument in revealing
God’s purpose for mankind and in reminding the patientthat ultimately all belong to God and return to him for a
new stage.
However, many Muslim scholars agree that patients inpain from terminal illnesses may receive analgesic
medicine until the time of death, which is in line with theprinciple of facilitation of hardship. Although no one isallowed to deliberately end a patient’s life, using
analgesic treatments may be permitted for a dying
patient, even if death is hastened; this is based on theprinciple that says: “actions are judged by theirintentions”.
It must be noted that autonomy is of less significance inIslam as compared with Western ethics; life is a gift of
God and whenever there is effective treatment, it should
not be rejected by a patient. Treatment cannot be denied
from a patient even by the patient's own request.
However, a patient cannot be compelled with force toreceive a painful life-saving treatment (such as
chemotherapy); it is for the patient to understand that his
refusal may be a big sin and that his afterlife well-being
could suffer from such decision. As such, respect toautonomy or avoidance of pain may not justify refusing
treatment.
Some Islamic teachings consider pain and discomfort
to be the expression of God’s presence; and as such,
freedom of pain is not an acceptable excuse for ending
one’s life. It is possible that suffering of a patient is adivine plan for his spiritual purification. However, if there
is no medical justification to continue (futile) treatments
and this may only prolong the dying process, Islam
allows the use of palliative care, as opposed to curative
treatments. But it is better to avoid palliative care which
shortens the patient’s life.
According to Islam, the length of one’s lifetime isdetermined by a divine decision. Therefore Islam does
not recognize a patient’s right to die voluntarily. Life is adivine trust and should not be terminated by any form of
euthanasia. No patient has the right to receive assistanceto die; life is a divine trust and does not fully belong to thepatient. Humans are responsible for the right stewardshipover their bodies, which are considered a gift from God.
Muslims have duties toward the God and fellow humans
that should not be neglected. Autonomy over one’s bodyis recognized in Islam but has secondary importance tothe afore-mentioned responsibilities. Therefore, humanlife is not to be terminated by any form of active or
assisted euthanasia.
Suicide is commonly held as abominable in Islam andstrictly prohibited. Unbearable pain because of illness is
not a justified excuse either. Quran 4:29: “…and do notkill yourselves; surely God is Merciful to you”.
According to Islamic teaching, Muslims should beready for the moment of death when the time comes; inIslam therefore it is not acceptable to resort to futile

Eubios Journal of Asian and International Bioethics 22 (March 2012)
treatments in order to put off death. In cases where there
is a reason to withhold or to continue the treatment,
availability or limitation of resources may be important indecision making; Islam emphasizes on helping eachother whenever it is possible. Age, gender, social
position, etc should not be used as the basis for selectionof the patients to be saved, but the priority is for medical
need and the probable outcome of intervention. Justice
may need to be taken into account too. Among
unconscious patients, the decision should be based on
the expected results of treatment and with due
consideration of the best interests for the patient.
When the patient is a child, Muslim parents have theresponsibility to consider these issues to the best of thechild’s interests after consulting with the physicians.
Children in Islam are valued as individuals with inherent
rights; they should be treated with respect. When thequestion of withdrawal of life support is raised forchildren, most parents in Iran find it unacceptable; they
do not want to be seen as playing a role in their child’s
death. However, in a situation that the child is not on life
support and a DNR (do not resuscitate) decision is being
made, most parents do not object to the decision.
Islam values the spiritual health, and moral
considerations of the persons involved in decisionmaking, besides the physical health and comfort of thepatient. Some Muslim jurists believe that in all cases it ispossible to reach a collective decision not to prolong thelife of a dying patient after consultation with the involved
physicians and family members.
The principle that says: “No harm shall be inflicted orreciprocated in Islam” (la zarar va la zerar fi Islam) is thebasis for making distinctions and ruling over life support
treatments in dying patients. An important distinction isover killing a patient through active euthanasia versus
letting him die. For example; withholding or withdrawing
treatment in a brain-dead patient would not be
considered unethical. Islam allows a dying patient (or his
guardian) to refuse treatments that may not improve theircondition or quality of life. Also, Islam may allow a patient
to refuse treatments that may delay death, after
consultation with the doctor and their family. Most Muslim
jurists believe that once invasive life support has been
started to save the life of a patient, life-saving equipment
cannot be turned off unless the physicians later becomecertain that death is inevitable. Such cases are permitted
when (financial) resources are limited and delaying theinevitable death of a patient through life-support is not in
the best interest of the patient or the public. Therefore
they can allow death to follow its natural course.
In recent years, living will has been used for suchcases in the Islamic Republic of Iran. Legally speaking, in
Iran a decision to end the life of terminally ill patients attheir request is beyond a doctor’s obligations, and there
may be no legal immunity for physicians who unilaterally
and actively assist a patient to die.
Sanctity of life is a fundamental principle in Islam.
Every moment of life has value and must be preserved.
Taking a person’s life may only be justified in rare
circumstances, such as for murder. Although the Islamic
belief is that all healing ultimately comes from God,
Muslims have a duty to seek out medical attention when
ill and they must receive appropriate medical care. The

73

physician also has an obligation to attempt to heal thepatient. However, according to Islam death is an
inseparable part of being human. Therefore, treatmentsthat only prolong the final stages of a terminal illness are
not obligatory.
When a Muslim is near death, those around him/her
are supposed to give comfort, and remind the dying ofGod's mercy and forgiveness. They may recite verses
from the Quran, give physical comfort, and encourage
the dying person to recite from Quran and to do prayers.
It is also recommended, when possible, for a Muslim's
last words to be the declaration of faith: "I bear witnessthat there is no god but the God (Allah)."
Generally in Islam, especially among Sunni Muslims,
those with a dying patient are encouraged to remain
calm, pray for him, and to begin preparations for burial
soon after his death. One should strive to be patient, andremember that it is God who gives life and takes it away,
at the time that only the God determines. It is not forhumans to question the God’s wisdom in death and it isforbidden to mourn excessively. It is said that when theProphet Mohammad's own son died, he said: "The eyesshed tears and the heart is grieved, but we will not say
anything except which pleases our Lord."
However, such an emphasis on refraining fromexcessive mourning is not observed among most Shi’a
including those in Iran; grief is normal when one has losta loved one, and it is natural and permitted to cry loudly.
Shi’a Muslims in Iran commonly cry in a loud voice andrdththhold many mourning ceremonies on the 3 , 7 and 40
day after someone’s death. After that, there areanniversaries where the relatives and friends may gather
to remember, recite and cry over the dead person.
Iranians are very well familiar with death. Many of theelderly live at home with other family members and die athome. Almost all family members are involved in burial
rites and the expression of death in these rites is often
dramatic.
Muslims usually wish to die at home when possible.
Death in a clinical setting at a hospital is not a favorable
Islamic tradition. The dying person may expect to bevisited by friends and relatives. This is a time when
Muslims seek each others' forgiveness for mistakes that
may have committed. The use of a hospice would
therefore be an advantage for a patient whose death isjudged as inevitable by the physicians. However, the useof hospice is still not an established way in the Iraniansociety. Many hospice services are provided at privaterooms in a hospital or a nursing care facility, but they are
not available at a nationwide scale and the majority may
not have access to specialized services available in a
hospice. The attitudes of the nursing staff towards dying
patients may also need to change (Iranmanesh et. al.
2008~2011). Besides the need for a change in theattitude of the physicians and specially nurses and othersupporting staff, two other major problems in protecting
the dignity of the dying patients in Iran remain. One is therelative lack of progress in provision of professional
services such as palliative care in a hospice setting, andthe other is the financial difficulties of many patients andtheir families associated with the small depth and breadthof the insurance coverage and the relatively high costs ofprofessional care for the average Iranian income.

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Disclosure of end of life issues and truth-telling topatients and their families in IranIn Iran, physicians’ paternalism towards their patients is
common; they may make decisions without involving thepatient in the process. Many physicians have notreceived proper training to understand the need for better
communication with patients or learn the skills to do that.
They often recommend what they believe is the best
option for the patient, based on medical and moral
factors as well as prior experience. This issue was
examined in a study by a group of oncologists regarding
disclosure of cancer information to patients in Iran
(Ghavamzadeh, 1997). Most cancer patients in Iran arereferred to oncologists by general practitioners, internal
medicine specialists or surgeons. Many cancer patientsfeel anxiety or fear after being informed of the fact they
have been referred to a cancer specialist; therefore
sometimes the referring physician does not inform thepatient or his/her family that they are being referred to an
oncologist. In many cases, the patients have not been
informed of the cancer diagnosis or its possibility.
A culturally relevant factor to this issue is thesignificance of the concept of "family" among Iranianpatients. Relations in the family and the associatedsentiments are strong and are usually dealt with greatcare. The difficulty faced by a family member affects
other members of the family and the expression offeelings could become a very sensitive issue. The
diagnosis of cancer strikes not only the patient but also
the family as a whole. When a patient is informed directly
or indirectly about the diagnosis of cancer, his or her
psychological balance may become severely disturbed.
Sometimes a severe reaction can endanger the medical
situation and the treatment process; such a reaction may
happen irrespective of the educational level or economic
class of the patients (Ghavamzadeh, 1997).
Therefore, the common tradition among physicians in
Iran has been to reduce information to cancer patientsand patients with poor prognosis and to respond to theirquestions in a very general way. Although nowadays
some patients press the doctors to get more and moredetailed information about the meaning of their diagnosis,
the cause of their disease, and its prognosis,
experienced oncologists often resist and do not provide
information about cancer and poor prognosis except
when they are legally required to. Generally physicians
prefer not to tell the patient directly, even if they arecompelled to provide the diagnosis to the legally
responsible person. The diagnosis is generally disclosed
to only one member of family. When the doctor decides
to disclose the information and diagnosis to a patient, he
usually considers the patient’s age, intelligence, andemotional stability, what the patient already knows of thedisease, the structure of the patient’s family, and thesocial status of the patient and his family. A common
practice is to tell the information to selected members of
the family; a selected member may simply appear to bebetter able to understand the diagnosis and prognosis
and yet remain stable and continue to cooperate with thephysician in providing information to the patient’s
relatives who are legally important for decision making
and economic support. A patient’s son-in-law, daughter-in-law, or grandson may provide such liaison. Finding
such a person is sometimes difficult; questionnaires filled
out by the doctor’s secretary, a ward nursing staff, or
admission personnel are in part designed to help findsuch a person. However, if the patient is a child, for legal
reasons the diagnosis is disclosed to his or her parents.
A more recent study to assess Iranian patients’preferences for disclosure of information and their
participation in decision-making has given different
results (Asghari, 2008). This study showed that Iranianpatients were interested in receiving information about
their condition and participating in clinical decisionmaking. No variable was found to be predictive of such
attitude and therefore the authors recommend that thephysician should explicitly ask the patients about it. In
this study the desire to receive information was somehow
greater in women than men and was also correlated with
their education and their estimation of the severity of theirown disease.
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6- Clarfield AM, Gordon M, Markwell H and Alibhai SMH. EthicalIssues in End-of-Life Geriatric Care: The Approach of ThreeMonotheistic Religions—Judaism, Catholicism, and Islam.
Journal of the American Geriatrics Society. 51(8):1149–1154,
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8- Ghavamzadeh A and Bahar B. Communication with theCancer Patient in Iran, Information and Truth. Annals New
York Academy of Sciences. 809: 261–265, 1997.
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Sadat, Eysa Mohammadi, & Gholamreza Babaee.
Development of a Community- based Care System Model for
Senior Citizens in Tehran. The Internet Journal of Advanced
Nursing Practice. 8(1), 2006.
10Larijani Bagher, Malek-Afzali Hossein, Zahedi
Farzaneh & Motevaseli Elaheh. Strengthening medical ethics
by strategic planning in the Islamic Republic of Iran (Country
Report). Developing World Bioethics, 6(2):106–110, 2006.
11Larijani Bagher & Zahedi Farzaneh. Contemporary
medical ethics: an overview from Iran. Developing World
Bioethics, 8(3):192–196, 2008.
12Larijani1 Bagher & Zahedi Farzaneh. Medical Ethics
Activities and Plans in Iran at a Glance. Iranian Journal ofAllergy, Asthma & Immunology. 6(5):1-4, 2007.
13Larijani Bagher, Zahedi Farzaneh, & Malek-Afzali
Hossein. Medical ethics in the Islamic Republic of Iran.
Eastern Mediterranean Health Journal, 11(5/6):1061-1072,
2005.
14Mahboubeh Rezaeia, Mohsen Adib-Hajbagherya,
Naima Seyedfatemib, & Fatemeh Hoseinic. Prayer in IranianEubios Journal of Asian and International Bioethics 22 (March 2012)cancer patients undergoing chemotherapy. Complementary
Therapies in Clinical Practice. 14:90–97, 2008.
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Salsali . Spiritual aspects of end-of-life care for Muslim
patients: experiences from Iran. International Journal of
Palliative Nursing. 2005 11(9):468-74, 2005.
16Rathor MY, Abdul Rani MF, Mohamad Shah ASB, Bin
Leman WI, et al. The Principle of Autonomy as Related to
Personal Decision Making Concerning Health and Researchfrom an ‘Islamic Viewpoint’. Journal of the Islamic Medical
Association of North America, 43:27-34, 2011.
17Sachedina Abdulaziz. Islamic biomedical ethics,
principles and applications. Oxford, 2009.
18Sachedina Abdulaziz. "Right to Die?": Muslim Views
About End of Life Decisions. University of Virginia website:
http://people.virginia.edu/~aas/article/article3.htm accessedon November 2011.
19Sedigheh Iranmanesh, Abbas Abbaszadeh, Helen
Dargahi, Mohammad Ali Cheraghi. Caring for people at theend of life: Iranian oncology nurses' experiences. Indian J
Palliat Care. 15(2):141-7, 2009.
20Sedigheh
Iranmanesh,
Habibollah
Hosseini,
Mohammad Esmaili. EvaIuating the "good death" conceptfrom Iranian bereaved family members' perspective. Journalof Supportive Oncology Abstracts. 9(2):59-63, 2011.
21Sedigheh Iranmanesh, Helen Dargahi, & Abbas
Abbaszadeh. Attitudes of Iranian nurses toward caring fordying patients. Palliative Support Care. 6(4):363-9, 2008.
22Sedigheh Iranmanesh, Zahra Ghazanfari, Stefan
Sävenstedt, Terttu Häggström. Professional development:
Iranian and Swedish nurses' experiences of caring for dying
people. Journal of Palliative Care. 27(3):202-9, 2011.
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Bagher. A two-decade Review of Medical Ethics in Iran.
Iranian Journal of Public Health. 38(1):40-46, 2009.
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Javad. End of Life Ethical Issues and Islamic Views. Iranian
Journal of Allergy, Asthma and Immunology. 6(Suppl. 5):515, 2007.
25Zahedi Farzaneh & Larijani Bagher. National bioethicallegislation and guidelines for biomedical research in theIslamic Republic of Iran. Bulletin of the World HealthOrganization. 86 (8):630-634, 2008.

Policy Analysis of Measures
Taken Against the H1N1
Influenza Virus of 2009
- Shinya Ueno, Ph.D.
Professor, Center for Policy Studies, Kumamoto University,
Japan
Email: ueno@gpo.kumamoto-u.ac.jp

1. Introduction
To prevent influenza infections using cutting-edge
science, technology, and other knowledge, international
efforts have been made and various domestic systems
have been established in countries around the world.
However, instead of a decrease being seen, virustransmission has accelerated on a global scale, in largepart due to an increase in the number of itinerant people.
In order to utilize knowledge gained from medical andpharmaceutical studies to defend society and benefit
human beings, various technologies involved indevelopment of new medicines, advances in treatment

75

techniques and studies into infection prevention systems
have been integrated as elemental technologies in one
integrated system. To apply such technologies in the realworld, effective policies need to be developed. However,their implementation is determined in the politicalprocess, which is formed by opinions of experts and theheavy influence of mass media, influences politics in its
turn, creating an intertwined relationship, as seen in theprocesses of policy-making, policy implementation, andpolicy evaluation.
How can society respond to threats from unknown
infectious diseases such as the new, more virulent typesof influenza or SARS, or to other situations beyond
anticipation? Is it possible to make better policy
judgments by utilizing expert knowledge and a wisdomthat prevents public opinion and sentiments from runningwild? Like other natural disasters, epidemics require
serious attention and preparation. However, as Torahiko
Terada has said, “it is easy not to be frightened enoughor to be too frightened, but it is difficult to be reasonably
frightened”(Terada 1961). After all, when surrounded bymedia coverage that can easily be whipped into a frenzy
but cooled down just as easily, and overwhelmed byvarious subjects both jocular and cruel, can citizens learn
to act in a socially appropriate manner? I would like toreflect upon the chaos caused by the H1N1 influenza
from the perspective of the social sciences and consider
the relationship between scientific technology andsociety. From a social sciences perspective as well, how
to develop policies for preventing infectious diseases
such as the new influenza that have great risk of causing
tremendous damage is an extremely intriguing topic.
2. What happened in 2009
The new influenza virus was detected in Mexico in2009 and rapidly spread first to the United States andCanada and then across 214 counties in just nine weeks;
as a result, the United Nations World Health Organization(WHO) declared an influenza pandemic on June 11 ofthat year (Kawaoka, Horimoto 2009, Sena 2009, Sotooka2009). Although there have been many cases in whichvirulent influenza caused serious social crises, such as
the Spanish flu pandemic of 1918, the crisis of 2009 was
the first time that modern Japan has needed to
implement defense measures against infection on a fullscale (Crosby 2004, Hayami 2006).
Specialists in Japan had previously fussed about thedanger of the unknown avian flu (N5N1), which was
highly lethal and potentially mutagenic. As a part of themeasures against it, action plans were being prepared atboth the national and municipality levels. This was thepoint at which the new influenza was detected. The
government announced to the public that the flu wasconsidered to be highly lethal and they would stop it at
the borders of the country. They also said that a priority
approach would be taken for vaccination as vaccine
production would not meet the demand. They
encouraged people to stay home, wash their hands,
gargle frequently, and stock up on water and food. TV
and newspapers provided space for various specialists
and authorities, reporting the status of the flu daily in a
provocative and sensationalistic manner. As people
started paying more attention to sanitation, they bought

76

Eubios Journal of Asian and International Bioethics 22 (March 2012)up sanitary masks and other supplies, the shortages ofwhich resulted in increased public anxiety.
Fear was also amplified by footage of quarantine
officers in white protective gear getting on planes that
had just arrived at the airport from overseas and making
thorough investigations and scenes, in which peoplesuspected of febrile symptoms were placed in strict
quarantine. When high school students in the Kansai
region cities of Kobe and Osaka were found to be
infected with the ‘new-type flu’, the Minister of Health,Labour and Welfare made an emergency statement to
the public on TV telling people to act calmly; however, his
statement had the opposite effect, increasing the senseof crisis surrounding domestic infections. Where
infections were found, patients, schools and entire
regions were immediately attacked by accusations andhit hard by rumors. Family members of patients andprincipals of their schools made apologies in front of thecamera. The media repeatedly reported such scenes,
turning them into a kind of kangaroo court the likes ofwhich are frequently seen in Japan following various
incidents.
In retrospect, we can see that the outbreak was not ofa highly pathogenic influenza as initially suspected andits infectiousness was no different from theinfectiousness of ordinary seasonal flu. The epidemic
ceased, and many vaccines hastily developed andmanufactured or imported were left unused. Of course,
some efforts paid off. Patients who were not accepted athigh fever–outpatient clinics were sent to general
hospitals, where all kinds of efforts were made to keep
infections under control while giving medical treatment
and focusing on preventive measures Some schools
were temporarily closed if necessary, and people were
exceptionally conscious of sanitation. All of these efforts
contributed to minimizing the damage from the flu.
Japan’s fatality rate among people contracting it was
0.2%, which was extremely low compared to Mexico(2.9%) and of the United States (3.3%) (Figure 1).
Although this new-type influenza shook the world, its
global death toll from it was 18,097, which is less than iscommon for this type of epidemic. In Japan, the damage
was even less than damage from the usual seasonal
influenzas in terms of excess mortality (Japan Medical
Association 2010).
During this process, our experiences gave ride to
many issues to be considered from the perspective of thesocial science—measures to be taken in addition to what
we can do medically and pharmaceutically against newtype influenza. Let us now take a look at those issues inorder.
3. Seriousness of the issue and difficulty ofprediction
In recent years, the highly pathogenic avian flu has
been raging, mainly in Southeast Asia. Scientists suspectthat the flu, which is currently only infectious among
birds, may in the near future mutate and become a highly
lethal avian flu that is also infectious among humanbeings. The WHO and the governments of many nations
have developed various strategies against this possibility.
After the WHO updated its definitions of pandemic
phases and alert levels in 2005, Japan came up with the

Action Plan for Measures Against New Influenza in thesame year. Based on this, the local governments
established their own action plans.
A certain pattern detected in the epidemics of the past
influenzas and the spread of the avian flu to poultry farms
within the country had raised concern about thepossibility of human-to-human spread of the avian flu. It
was in this atmosphere that the new influenza exploded
in Mexico and spread throughout the United States,
leaving an impression that the flu might be an extremely
ferocious, highly pathogenic avian flu. The flu wassuspected of being highly virulent due to its fast rate of
infection and high mortality rate. Although gene analysis
revealed that it was not avian flu (H5N1), but swine flu(A/H1N1), the WHO declared an influenza pandemic, andJapan
automatically implemented
measuresinaccordance with the manual, which had been preparedand intended for the worst avian flu.
Let us look into this experience from the standpoint ofpolicy analysis. There are usually three approaches inpolicy analysis case studies (Dune 2003). The first
approach is to study cases from the “past” to see whether
they were right and consider what the problems were.
This is post hoc analysis, but it is often used in the field ofsocial science as a research method to gain knowledge
on what happened then or what should have been done.
However, whether these cases in the past could beapplied to the present and the future is another matter.
Generally speaking, it an effective approach whenevaluating the policies of the past in retrospect.
Descriptive analysis or normative analysis is the main
tool used in this approach.
The second approach is to study the “present.” In thisapproach, we explore what get good results in ongoingcases and deal with issues through experience. In areas
such as clinical medicine, this is generally very important.
However, from the social science perspective, since notenough data is provided, our perceptions would be
intuitive and tentative only, requiring analysis from anormative viewpoint. The third approach is to put theemphasis on predicting what should be done in the“future.” The purpose here is to describe an efficient,effective policy scenario to make the future desirable;thus, it is an analysis that comes from a future-predicting
perspective. This is essential when considering what
policies to develop in the future, but it does not contributeto solving the issues of the present and only provides
uncertain predictions for the future. However, thisapproach is the main one employed in the field of policy
science where policy-making is scientifically studied.
At this point I would like to explore how the responseto the flu pandemic was from the viewpoint of evaluating
the past and also from the perspective of policy-making
to gain knowledge that can be utilized to develop better
policies in the future. Here, benefits, risks, and costs are
the crucial factors to determine whether a policy is agood one or not.
First of all, the reason why it is difficult to establish
measures against new types of influenza is because it is
impossible to predict their virulence or spread in
advance. We have no way of knowing what kind of flu
may spread, as a result of mutation, how infectious it may
be, and what the rate of fatality or spontaneous recovery

Eubios Journal of Asian and International Bioethics 22 (March 2012)
is. Information on public health has to be collected
through various channels around the globe, and as soon
as there is a suspected case of an unknown disease, an
epidemiological study team is sent to test its
pathogenicity. This information is shared among nations
to prevent infections and to establish effective policies ineach country. Such steps have already been undertaken
by means of international cooperation. Here, hardscience, in mainly the medical and pharmaceutical fields,
is expected to play an important role in determining whatkind of virus is afoot, containing it within the area alreadyinfected, immediately developing and manufacturing
appropriate vaccines, and spreading effective treatment
methods and prevention measures.
However, infectious disease specialists have different
predictions and perceptions concerning what type of virus
will be born next and how pathogenic it will be. It requires
a certain amount of time and funding to develop andmanufacture vaccines or to prepare preventive medicines
on a national scale. Since the apprehension of scientists
that an unknown and highly lethal influenza will emerge
in the near future has been considered well founded, theperceptions of infectious disease specialists have beenemphasized in the process of policy-making for thedevelopment of specific countermeasures.
In this respect, there is an interesting case of a policy
adopted by the government of the United States thatshould be considered here (Neustadt & Fineberg 2009).
In 1976, moved by the opinion of an infectious disease
specialist who suspected that a new type of highly lethalswine flu may have erupted in the United States and by
the CDC (Center for Disease Control) which had beenhighly influenced by the specialist, the government, whichfeared a pandemic like the Spanish flu, adopted a policyof unprecedented scale involving the vaccination of all
citizens within the country. However, the government
faced many political and logistic challenges in
implementing this policy. For instance, it took eightmonths to manufacture the vaccines and the government
found itself having to come up with a grandiose plan tovaccinate citizens for the first time. Further, because
private insurers refused to compensate policyholders forpossible side effects of the vaccines, the process was
suspended; it resumed when the government promisedcompensation for people suffering debilitating side
effects. Another political factor was the consideration on
the part of Gerald Ford who had assumed the Presidency
after Nixon’s resignation towards the 1976 Presidential
Election. In the face of dissention from staff members
who said that vaccinations were a bet with no chance to
win either way and would bring no positive outcome interms of the election campaign and opposition from
America’s three major TV networks, President Ford madea firm decision for the people of America. As it turned out,
only one person died from the flu, and a few more wereseriously infected at a US army base; no broad contagion
occurred within the country.
The policy had been initiated as an emergency projecton an unprecedented scale. The system of mandatory
vaccination came at a huge expense and shook theentire nation. However, even this came to a halt when theassumption of a crisis collapsed. But the matter did not
end there. The plan was aborted after the vaccines

77

prepared for 100 million people had been given to thefirst 40 million, but this resulted in a tragedy with thesubsequent deaths of 32 people from a disease called
Guillain–Barr syndrome, a possible side effect of thevaccination, and a few hundred more suffered from otheraftereffects. The lesson learned from this experience wasthat we should not only listen to infectious disease
specialists and respect their opinions, but also verify
whether the risk has been properly evaluated andexamine the logic, probability, and social compatibility ofvaccination from the viewpoint of non-specialist third
parties.
Ulrich Beck calls modern society a “risk society” (Beck1998). We live in difficult times where we have no choice
but to believe what scientists have to say about various
dangers that we cannot detect with our five senses. Eventhe estimates of specialists are limited by the boundaries
of our knowledge of the moment. The degree of risk ofinfectious disease, nuclear disaster, earthquakes, andvarious other calamities is indicated by hard-tounderstand scientific figures and probability rates thathave not heard of and we cannot even understand. In
today’s society, scientists in the front line predict what therisk will be using statistics and a probabilistic approach.
When incorporating scientific knowledge into the policymaking process, it is difficult to find a metric upon which
to base political and social judgments. In other words,
policy-makers need to consider how they can secure thevalidity boundaries both of experts and the public, on thepremise that scientific rationality is different from social
rationality (Fujigaki 2003). The issue is the difficulty
applying scientific knowledge, which cannot provide
flawless predictions, to the real world, and how we fallible
humans must decide on what course to take despite ourlack of predictive capability. Such principles as disclosureof information, transparency of discussion, clarification ofdecision-making processes, stakeholder participation andtheir representativeness, and preservation of a wide
variety of choices are what secure social rationality. It isparticularly hard for scientists to convey information in a
way that allows the layperson to understand what has
and has not been scientifically elucidated. If this line isblurred, then people will never be able to avoid the kindsof failure repeatedly experienced in the past as seen in
the reaction to the BSE (bovine spongiform
encephalopathy) crisis or in the risk assessment for the
Fukushima nuclear accident both of which involved
scientists (Kobayashi 2007). In these cases, discussions
among scientists were focused only on ascertaining theempirical correctness of their understanding of theissues, thus skewing judgments in the actual world where
politics, economics, and social attitudes also need to beconsidered.
3. Difficulty of policy selection
When people cannot sense any risks on their own
accord and need to rely on complicated and advanced
scientific predictions, where do the politicians andadministrative officers who play the role of converting
those predictions into specific policies come in?
First of all, politicians need to gauge the anxiety of the
public and discuss what measures need to be taken in its
context. When a highly lethal and contagious disease is

78

Eubios Journal of Asian and International Bioethics 22 (March 2012)detected and there is a risk of affecting an entire nation,
how do they deal with it? The degree of risk is likely to behighly uncertain. The disease may cause serious
damage or it may not. Decision-makers surely listen towhat scientists have to say, but they cannot fully
understand or realistically grasp the probability
breakdown of the possibilities presented. If they are toprescribe some sort of measures, huge costs and efforts
come into play. Even if they accept these costs,
implementation may not be possible quickly enough or
may be flawed or futile. On the other hand, if they decide
to do nothing and the risk becomes reality, politicians
have no means of avoiding blame from the public. The
ultimate decision-maker is the government; butpoliticians, who fear a backlash against controversial
policy, may try to avoid doing anything. Of course, thecost of missing the opportunity to act is huge too. Whenconsidering the possibility of causing critical damage tothe populace, policy-makers may well choose to go for amore tolerable failure as the lesser evil to doing nothing.
This was the choice the Ford administration in the UnitedStates made in the case mentioned above.
However, even infectious disease specialists may
have different outlooks and come to different predictions.
Will the opinion of a less-informed scientist who happens
to have a strong political network or be good at
expressing what he or she thinks be adopted? And whenthe media becomes interested in the issue, scientificdisagreement that is presented wrong may end up
amplifying the anxiety of the public. Currently, forinstance, in the aftermath of the Fukushima disaster, therange of opinions that exist among specialists concerning
the risk of radioactive contamination is fostering a senseof popular distrust toward science, scientists, and needed
measures. A similar situation could develop in the context
of various more-or-less invisible risks.
Escalating media attention will stir up the anxiety ofthe public. That is the nature of the news. Officials are
restricted by slippery public opinion, as citizens cry “whatare the politicians doing?” Politicians obsessed with theneed for “political leadership” will have no choice but toproject an image of being the leaders of the discussion,even though they are not experts on the subject, and as
a result they may be pushed and forced to makedecisions that are uninformed or ill-advised, seeking an
expedient answer.
The administration will then accept such politicaldecision and implement specific measures. The best way
to proceed in the case of a potential pandemic is on thebasis of standard procedures laid down in manual form inadvance. However, in the case of the new flu, the only
thing prepared in advance was a crisis-management
manual intended for a highly virulent avian influenza.
Even after the virus turned out to be a low-virulenceswine flu, national and local government, medical
institutions, NGOs, and businesses were forced to follow
through with top-level measures intended for a worstcase scenario since no appropriate measures had been
prepared. From the perspective of specialists in thedomain, it seems like the right approach to prepare forthe worst. For instance, the action plan prepared by
Kumamoto Prefecture stipulates that “at the beginning,
we take powerful measures because the pathogenicity

and infectiousness are unknown, but as soon as they areclarified, we switch to appropriate measures based onwhat the government will do” (Kumamoto Prefectural
Government 2010). In reality, however, to use discretion
and adjust the response flexibly while carefully watching
how things develop is already at this point an impossible
task for the administration alone.
At medical institutions, immigration and quarantine
control facilities, and schools, people were in extreme
confusion as they found that the top-level measuresdescribed in the manual were impossible to follow
through in the first place. Even after it was revealed thatthe flu was not a truly horrible strain, but was only as
serious as an ordinary seasonal flu, people onsite were
not able to think or act flexibly. Thus, the whole system
gradually faltered and failed. Just how effective, forinstance, was the “border strategy” to strengthen
quarantine control implemented from April 30 throughJune 18? This experience raised fundamental doubts
about whether this border strategy would really beeffective with virulently infectious diseases (Kimura2009). An organization called the Fever Advice Center,established to secure well-ordered treatment systems,
found that it had no choice but to accept any patientswith fever, and was quickly overwhelmed. At first, when
patients were identified they were immediately
hospitalized. But this approach had to be stopped
because the number of the beds was inadequate tosupport it.
It is also necessary to investigate whether the priority
sequence of vaccinations was really appropriate after all.
Excluding healthcare professionals, vaccinations were
given in order to pregnant woman, people with preexisting diseases, children from age one to school age, ,children in the early elementary grades, guardians ofchildren under a year old and guardians of those who
could not be vaccinated among priority cases. In addition,, children in the later elementary grades, middle school
students, high school students, and elderly people (aged
65 and over) were vaccinated in order of priority. Thissequence seems to give priority to the sociallyvulnerable. On the other hand, the infection in factspread mainly among young people who were in contact
with a group of people outside the home on a day-to-day
basis, such as schoolchildren and university students,
who are the main vehicle of transmission. Studies showthat it would be more effective to vaccinate these young
people before the elderly, who do not often go out ingroups, if the goal is to stop the spread of infection to theentire society. This would suggest that it would havebeen more effective to give priority to vaccinating
students in elementary schools, middle schools, highschools and colleges as they are the primary source forthe spread of infection. The question of how a limited
number of vaccines should be used generates a conflict
between scientific validity and political considerations.
A desk plan was prepared that specified preventive
measures and treatments of the H1N1 influenza, but inretrospect, there were many inadequacies in the plan’s
adaptability to real life. Community medical institutions
mobilized all staff to treat patients, but the greatest
problem was that people on the line had limited freedom
to deal flexibly with reality. While society needs to beEubios Journal of Asian and International Bioethics 22 (March 2012)protected a state level, communities also need to have acertain freedom, so that flexible, specific measures canbe taken effectively in each scene. These needs must be
properly balanced in all relevant policies.
It is essential for the government to secure trust by
showing that it understands public anxiety and isaddressing issues properly. On the other hand, while no
one has the “best answer” to the question of how people
should respond to risk, the government still has to makedecisions that reflect a stance of the complex question of
how expertise and expert opinions should be applied tothe conditions of real life. It is important to verify or foster
broad public acceptance and support for scientificfindings with public health implications. The government
also needs to take on the difficult task of finding the bestsolution for the entire society while reconciling a wide
variety of interests such as citizens and businesses thebalance between which it is responsible for. The final
decision is to be made by the government, but they are
required to seek social rationality in the process leading
up to the decision. Upon doing so, it is vital to balance
the “discourse of truth” and the “discourse of consensus”
from the perspective of risk communication. But at thesame time, it is also important to secure a channel for acontinuous dialogue on other options to anticipate andeliminate any unexpected problems (Yamori, Yoshikawa& Amisiro 2005). In 2009, the prompt response of theJapanese government deserves credit, but leadership
was lacking to modify approaches as needed while
paying careful attention to developments and they lacked
the capacity to effectively implement measures. On May
9, the minister made a sensational appearance on TV
and excitedly announced that the country’s first case of
the new flu had been detected. This attitude was seen as
strange in a government official. The minister shouldhave demonstrated that he understood the scientificprognosis for the spread of this disease and intended tohandle matters calmly and rationally.
4. Media response and public response
In this case, the media was able to inform the publicof the flu crisis in a helpful manner, educating people in atimely fashion with information on sanitation such as
hand washing methods, coughing etiquette, and the needto stay away from crowds to prevent infection as much as
possible. This had an immense effect that could hardly
have been achieved by government and healthorganizations.
However, there was a big downside to this media
involvement. As media coverage became extensive,
specialists and “self-proclaimed” authorities emerged andspread various unsubstantiated theories. This graduallychanged the quality of the information that the media
passed on. Not only official broadcasts and science
programs but also variety shows and other entertainmentshows began to cover the flu, exaggerating the scale ofthe problem and inducing anxiety. Media coverage was
becoming a media circus, making the flu look like anexistential threat (Figure 2). The people as well as
politicians were influenced by this media coverage, which
in turn spurred the media response, resulting in a vicious
circle. Patients were vilified, as were people responsible
for schools and other locations where the virus could

79

spread. Despite the fact that anyone could get infected,
some people directly contacted those infected or theirschools to blame them, while others contacted theadministrative bodies to find out which school infected
people went to or what company they worked for, as if
they were hunting down a criminal.
Figure 1 2009 H1N1 influenza - Number of people
infected and case fatality rate by country

The larger the space, the higher the number of people infected.
The darker the color, the higher the case fatality rate.

Figure 2: Frequency of the word “infuruenza” (influenza)
appearing in the Kumamoto Nichinichi Shimbun
Although the media did try to pass on accurate
information about preventive measures and treatment,
the value of this activity was overwhelmed by the impact
of continuous reporting of how many were newly infected,
where they had been infected, and how people wererunning around hastily buying up everything on shelvessiege. It was shown that the Japanese media are notcapable of responsibly handling the reporting of scientificinformation. It may that they are enslaved by bad habitsof commercialism that made them think that they could
not draw attention if the content was not entertaining, orthey could not differentiate themselves from others andas a result lose viewers if their content was notsensationalistic. Although Japanese mass media are
private companies, there is a basic requirement that they
exhibit a high degree of public and social consciousness
and to provide moderate reporting that is scientifically
based. Further, because the national government did notprovide a scientific explanation, the media focused onreporting factual information such as how many were80

Eubios Journal of Asian and International Bioethics 22 (March 2012)

infected and where the hotspots were and was unable toprovide the public with information from a broad
perspective. As a result, they kept sending out the
misguided message that the flu was a high-risk infectious
disease, which is another result that needs to bereflected upon.
In the cities and towns, people were seen here andthere running around to get food, water, medicines,
masks, and disinfectant, with masks always on. Because
distribution of goods was interrupted and people were
expected to stay home for a certain period of time torecuperate or for other reasons, they bought up
everything on the shelves. This may have been acautious and reasonable preparatory action in the
beginning, but quickly this purchasing behavior took on
its own life, and quickly nothing was left on the shelves;people were misled into thinking that supplies wererunning out, which pushed them to buy more things,
resulting in a chain of frantic behaviors, almost a panic
situation. (This was, however, a good opportunity to learn
that we should lay in a certain amount of supplies ineveryday life to be well prepared not only for natural
disasters but also for infectious diseases.) It is presumed
that the temporary shutdown of schools and some otherbuildings to prevent group infection contributed
significantly to putting an end to the outbreak andminimizing its impact. In Kumamoto Prefecture, forexample, 27 preschools, 57 elementary schools, 18
middle schools, and seven high schools were temporarily
shut down. The total number of classes that weresuspended amounts to 4,365. The shutdown imposed anenormous burden on working parents with children
attending preschool or elementary school, who had tomake alternative arrangements for their children. Manycompanies placed employees with fevers or diagnosed
with the flu on leave. There were even cases in whichwhole companies shut down temporarily. At first, thegovernment took crisis measures, prohibiting people fromtraveling overseas and ordering them to return home. But
their response calmed gradually. Society learned fromexperience.
5. Lessons for the future(1) Be reasonably frightened
The estimated number of patients with the H1N1
influenza throughout Japan in 2009 was 20 million, thenumber of hospitalized patients was 18 thousand, andthe number of fatalities was 198. In Kumamoto
Prefecture, the estimated number of patients was
340,000, the number of hospitalized patients was 67, andthe number of fatalities was 5. If this had been a highly
virulent new influenza, as in the estimation model
developed by the government in which 25% of the entire
population is assumed to be affected and the pandemic
lasts for eight weeks countrywide, the estimated numberof patients would be 32,000,000, the number ofhospitalized patients 2,000,000, and the number offatalities 640,000. The action plan of Kumamoto
Prefecture projected the number of patients in theprefecture at 450,000, the number of hospitalized
patients at 30,000, and the number of fatalities at 9,000.
This is considered sufficient to cause serious social
disruption.

It is important to take measures to prepare for the
worst possible scenario. At the same time, it is also
important to flexibly shift to more proportional measures
as the scale of an outbreak becomes clear. A variety ofpolicy measures need to be prepared against infectious
diseases. In 2006, Kumamoto Prefecture developed atabletop flu pandemic simulation game called“Crossroad,” which demonstrates to players what
decisions various actors including administrative bodies,
medical institutions, health departments, schools,
businesses, electric power companies, and stores shouldmake when viruses are spreading. Simulations like this,in which people in various positions can participate, give
us valuable experience in terms of how to respond as asociety to pandemic conditions (Yoshikawa, Yamori &Sugiura 2009).
Another issue was the extent to which municipal andprefectural preparations and information from various
meetings should be passed on to medical andeducational
institutions.
The
Higher
Education
Consortium Kumamoto hosted a symposium on the
H1N1 influenza, which was proposed by the president of
one of the medical universities in the prefecture. It was agreat opportunity for faculty members at all theuniversities to obtain accurate scientific knowledge on theflu, and was very effective because they had a chance tomeet and consult with frontline medical researchers. In
2009, the flu epidemic ceased without incurring the risks
about which we had been deeply concerned. However,
we should not be overconfident that epidemics in the
future will also be minor. It is essential for us to acquire
accurate knowledge and neither develop an exaggerated
sense of crisis and nor be too optimistic.
(2) Knowledge to defend ourselves as a society andpopularization of social technologies
In modern society, we live in an environment where itis difficult to avoid infection once infectious diseases
become epidemic. Since anyone can acquire an
infection, we need to be equipped with the rightknowledge and know how to overcome viruses andminimize their spread.
Firstly, one major issue in Japan is our social aversion
toward vaccination (Tezuka 2010). Of course, there havebeen lawsuits over drug-induced suffering which werehighly publicized as a major social issue. However,vaccination is a very effective method to minimize thespread of diseases in society. Measles, influenzas, andmany other diseases would not affect us if we acquired
immunity. However, when people refuse to be
vaccinated, then these diseases continue to spread andmay become highly lethal. Of course, the possibility ofsome people falling ill or dying due to the side effects ofvaccines cannot be eliminated, but vaccines aredesigned to save the lives of a great many in society andto deny vaccination would not be rational or sociallyappropriate behavior.
Once a person is infected, medical andpharmaceutical approaches such as anti-influenza drugs
can be useful. However at the prevention stage, nonpharmaceutical preventive measures can be taken on an
individual basis. Everyone needs to follow coughetiquette, wearing a mask or covering the mouth with theEubios Journal of Asian and International Bioethics 22 (March 2012)
hands or arms to prevent the scattering of pathogens
when coughing. Some people sneeze without covering
their mouth on the train or in other places, but this should
be considered an offensive behavior, the product of willful
negligence of the risk of droplet infections and contact
infections to those around an infected person. Wearing amask is not as effective in terms of protecting the wearerfrom infection, but it is very effective in terms of nottransmitting the virus to others. The way people coughneeds to be more than a matter of etiquette; it should
become one of the rules of our society, to be followed byeveryone. Also, individual efforts such as staying awayfrom crowds or washing hands thoroughly during
epidemics can be very effective in preventing infections.
Continuing to work or go to school when feverish is not
something we should do during epidemics of infectious
diseases. Staying in and recuperating at home will better
contribute to protecting society.
(3) Enhancing the capacity for scientific media
coverage
Infectious disease specialists and scholars in healthorganizations and universities are required to provide
accurate, easy-to-understand information so that mass
media can cooperate in offering scientific coverage to the
public. I expect the media to be able to fulfill its mission increating an atmosphere in society that helps people tocalmly cope with infectious disease without stirring up
panic or causing injury to those infected.
The H1N1 virus is just one of the many new kinds ofviruses and risks we need to continuously grapple with. It
should be the goal of public policy to help society
accumulate the knowledge and experience to cope withdiseases and risks.
References
Alfred W. Crosby “America’s Forgotten Pandemic: the Influenza
of 1918”, Tokyo: Misuzu Shobo, 2004.
Ulrich Beck “Risk Society: Towards a New Modernity”, Tokyo:
Hosei University Press, 1998.
Yoshihiro Kawaoka, Kiyoko Horimoto “Influenza Pandemic”,
Tokyo: Kodansha, 2009.
Moriyo Kimura “Ministry of Health, Labour, and Welfare and
New Influenza”, Tokyo: Kodansha, 2009.
Kumamoto Prefecture New Influenza Prevention Headquarters‘Verification Report on Measures Against New Influenza(A/H1N1)’ 2010.
Kumamoto Prefecture New Influenza Prevention Headquarters‘Kumamoto Prefecture Action Plan for Measures Against New
Influenza’ 2011.
Hideaki Sena “The Twenty-First Century of Influenza”,
Tokyo:Bunshun Shinsho, 2009.
Tatsuhito Sotooka “New Influenza Crisis: New Edition”, Tokyo:
Iwanami Shoten, 2009.
Yosuke Tezuka “Structure of Postwar Public Administration andDilemma: Administrative Changes concerning Vaccination”,
Tokyo: Fujiwara Shoten, 2010.
Torahiko Terada “Essay: Two incidents of small explosions” in“Complete Works of Torahiko Terada”, Tokyo: Iwanami
Shoten, 1961.
Japan Medical Association “The Journal of the Japan Medical
Association” 2010, Vol.139, No.7.
Akira Hayami “Japan Hit by the Spanish Influenza Pandemic:
Mankind and the First World War of the Virus”, Tokyo:
Fujiwara Shoten, 2006.
Yuko Fujigaki “Expertise and Publicness: Toward Establishing a
Theory of Science, Technology and Society”, Tokyo:

81

University of Tokyo Press, 2003.
Katsuya Yamori, Toshiko Kikkawa, Tsuyoshi Ajiro “Risk
Communication Learned Through Disaster Prevention Game:
An Invitation to Crossroad”, Kyoto: Nakanishiya Shuppan,
2005.
Toshiko Kikkawa, Katsuya Yamori, Junkichi Sugiura “Crossroad
Next”, Kyoto, Nakanishiya Shuppan, 2009.
Richard E. Neustadt, Harvey V. Fineberg “The Swine Flu Affair:
Decision-Making on a Slippery Disease”, Tokyo: Jiji Press,
2009.

Bioethical issues and HIV
stigma- Subarayan Nithianandam
Programme Coordinator, State Health Data Resource Center,
TNHSP, India
Email: essenn2000@yahoo.com

Introduction
This is a research report on the empirical study
conducted among pregnant mothers to elicit theirknowledge, opinion, attitude and to explore myths andmisconceptions associated with HIV stigma anddiscrimination and the bioethical issues involved
therewith. HIV stigma is explained as the prejudice,discounting, discrediting and discrimination directed atpeople perceived to have HIV or AIDS and at theindividuals, groups and communities with which they areassociated. AIDS is one of the most stigmatized diseasein history. HIV-related stigma is multi-layered, deeply
rooted, operating within the values of everyday life,
stigma plays into, and reinforces, social inequalities. If we
do not appreciate the nature and impact of stigma, noneof our interventions can begin to be successful.
The Genesis of Public Health Ethics
Modern bioethics emerged in the 1960s and 1970s andbegan to have enormous impacts on the practice of
medicine and research – fuelled, by broad socio-politicalchanges that gave rise to the struggle of women, but little
attention was given to the question of the ethics of publichealth. Recognising the role of moral values in decisionmaking was a signal contribution of bioethics in its
formative period. Over the past decades a broad array ofperspectives emerged under the rubric of bioethics but
individualism remains central.
Knowledge on AIDS Only eight in ten women have heard of AIDS.
 Nine in ten urban women have heard of AIDS
(93.4 percent).
 Two out of three rural women have heard of AIDS.
 Less than 10 percent of women with no education
have heard of AIDS (6.3 percent).
 Knowledge increases with education, womencompleted 10 or more years of schooling (69 percent).

Television is the source of information on AIDS,
reported by 80 percent of women who have heard of
AIDS.
 Television is the common source in all subgroups
including the rural and least educated populations.

82

Eubios Journal of Asian and International Bioethics 22 (March 2012) The next reported sources after television areradio.
Stigma associated with AIDS and accepting Attitude
towards HIV/AIDS Buying vegetables from a shopkeeper with
HIV/AIDS (47% - pretest and 70%- posttest).
 36 %in the post test (which was originally 10 % in
the pretest) of rural women say that they would not wantto keep it a secret if a family member had HIV/AIDS after
reading the print materials supplied to them.
 72.67 percent of the respondents feel HIV/AIDS as akiller disease in the pre-test have changed their opinion
in the post-test.
 On maintaining secrecy of family member’s HIV
infection, 63.33 percent disagree with that point in the pretest, in the post-test got clarity out of the print materials
and this stigma is reduced to 46.77 percent in the posttest.
Ethical Issues in Public Health Communication
 Ethical issues in public health communication are
explored as they relate to eight topics: ‘targeting’ and ‘tailoring’ public health messages toparticular population segments;
 obtaining the equivalence of informed consent; the use of persuasive communication tactics;
 messages on responsibility and culpability; messages that apply to harm reduction;
 and three types of unintended adverse effects
associated with public health communication activities
that may label and stigmatise, expand social gaps, andpromote health as a value.
It is suggested that an ethical analysis should beapplied to each phase of the public healthcommunication process in order to identify ethicaldilemmas that may appear subtle, yet reflect importantconcerns regarding potential effects of public healthcommunication interventions on individuals and society
as a whole.

Consideration of issues
concerning “Physician’s
Prescriptions” in the Practice ofOccupational Therapy in Japan- Katsuaki Yamano, OTR, BSPH, MA
Kumamoto-ekimae Nursing and Rehabilitation College
Department of Occupational Therapy, Kumamoto, Japan
Email: yamano0403@yahoo.co.jp

Introduction
The purpose of this study is to discuss the role of thephysiatrist’s prescription in the practice of occupational
therapy. We surveyed occupational therapists about
informed consent in the practice of occupational therapy
in August 2009 (Yamano, 2011). We clarified thatoccupational therapists have rationales for administering
therapy if clients do not consent to undergo occupational
therapy. One of the reasons is “occupational therapy ispracticed under the physician’s prescriptions”.

Due to the Japanese laws, practicing occupational
therapy without a physician’s prescription is against law.
We discuss if the physician prescribes, whether
occupational therapists can practice occupational therapy
for clients without consent.
Occupational Therapy Process in JapanThe laws that are the most important for Japanese
occupational therapists are Physical Therapist andOccupational Therapist Law established in 1965. In
Article 2-4 of the Physical therapists and Occupational
Therapists Law, The term “Occupational Therapist" as
used in this act means a person that is qualified licenseby minister of the Ministry of Health, Labour, andWelfare, use the style of “Occupational therapist”,
practice in occupational therapy unless physician’sprescription.
On the other hand, Ministry ordinances concerning fees
for health service care in Japan establish that it isperformed with director guidance of the physician, andthe occupational therapy calculates it about a thing
performed under the physician or the monitor of theoccupational therapist.
Occupational therapists in Japan need prescriptions topractice therapy with the law that we show after. We
evaluate for clients. Then, we classify the state offunctioning, and the real problem. Third, we makeintervention planning. We set long and short term goals,
and select and establish the way of therapy. Fourth, we
practice occupational therapy. The most of clients areprovided therapy from twenty minutes to an hour. Fifth,
we re-evaluate for client routinely. We validate the effectof therapy by comparing previous and current results ofevaluation data. If the client completes the goal, it may be
the end of therapy based on assessment by physician.
However, if not, we define the problem again (Figure1).
0. Prescription by Physician
1.Evaluation :Interview, observation, collecting information, measurement for clients
2. Problem Definition : on International classification of functioning(ICF)
To assess the results of evaluation and Define problem that are to be
repetition targeted through occupational therapy interventions
3. Intervention Planning :Goal setting, select and establish the way of therapy,
4. Intervention Implementation:
Verification of the effects every therapy
5. Re-evaluation :Systematically re-collect initial evaluation data and Compare evaluation
and re-evaluation data to determine if outcomes have been met anddiscontinuation is appropriate if not, determine subsequent action
6. completedFigure 1: Process of Occupational Therapy
Early Studies about Prescribing Occupational
Therapy
1. Standpoint of Physiatrist
Most of the early studies about prescribing occupational
therapy in the standpoint of a physician are written byphysiatrists. Lich mentioned that, “The prescription ofoccupational therapy is the selection of the activity orEubios Journal of Asian and International Bioethics 22 (March 2012)83

activities best calculated to relieve the patient of his
symptomatic pattern” (Licht, 1948 p.1032). Spencer
suggested that it should use the term “Referral” rather
than “Prescription” (Spencer, 1969). Martin mentioned
that, “Therapists should be cognizant of the principle thatan ethical, licensed therapist treats patients only with anadequate prescription or written instructions. The attitude
the therapist is to take―whether therapist should insist
on productive work or merely invite or encourage thepatient―should be indicated on the prescription” (Martin,
1971, p.511). Rask mentioned that, “The prescription
should be as specific as possible. In addition to theinformation given in the standard prescription, it isdesirable to indicate the reason for which the activity isprescribed and the anticipated result” (Rusk, 1977,
p.323). Before the 1970, based on the views that thephysiatrist examined, it seemed that it was desirable tomention prescription as much as possible in detail.
On the other hand, in a Japanese paper, it seems thatprescription about occupational therapy completes therelationship between physiatrists and therapists. Chino
mentioned that, “Prescription of Occupational therapy iscommunication tool between physiatrist and therapist”(Chino 1976, p.4) .Ogisima mentions that, “Whenoccupational therapy is therapeutic practice, therapist
must not practice without the prescription. But, if therapist
who has license and hardworking practice therapy,“referral” is an ideal than prescription” (Ogishima 1980,
pp.3-9). Hattori mentioned that, “Occupational therapy isheterogeneous area for physiatrists” (Hattori, 1984a,
p.762). “When physiatrists prescribe for patients
occupational therapy comprehensively, occupational
therapist will practice therapy who have special
knowledge and technique. A relationship of trust ofphysiatrist and therapist is necessary” (Hattori, 1984b,p.80). Ueda mentioned that “Physiatrist’s prescription is
not absolute and perfect. But the attending physiatrist
accepts ultimate responsibility for patients. Occupational
therapists must obey physiatrist’s prescription if
physiatrist prescribes contraindication or precaution
statement concerning frequency or density ofoccupational therapy, for example. Though occupational
therapists have rights and obligations to present if
therapists prompt the question concerning physiatrist’sprescription, it should resolve among the members of
rehabilitation medicine team as rapidly as possible”(Ueda 1992, pp.329-35).
However, Shinsya et al mentioned that, “Physiatrist
should prescribe for patients on assessment strictly. The
physiatrist having ability brings for patient good outcome
certainly. The prescription that keeps on entrusting fortherapists will lose the significance of existence of thephysiatrist”（Shinsya et al 2010,p.726）. Shinsya takes astance against leaving it entirely up to occupational
therapists.

because the Japanese law establish that physiatrists
have ultimate responsibility for patients in medical(Kamakura, 1971, p.405)
Terayama mentioned that, “The prescription is order oftherapy for patients with consensus between thephysiatrist and the therapist. Physician should indicate
risk factor for patient” (Terayama, 1976, p.7) , and “Theprescription is communication tool between physician
and therapist” (Terayama, 1990, p.283). Yatani
mentioned that, “In Japan, therapist recognize theprescription from physician should be absolute.
Physicians have grave responsibility to prescribe and tounderstand role of other members of profession” (Yatani,
1990, p.282).

2. Standpoint of Occupational Therapist
Mazer et al mentioned that, “The prescription has been
and is still a symbol of a close working relationship withthe physician, as well as important form of medical
supervision” (Mazer et al, 1958) .Kamakura delivered in
the discussion meeting that occupational therapists may
think to feel safe by complying physiatrist’s prescription

We consider that occupational therapists also hope tosupport for clients as their role for. However, especially,
therapists who do not have much experience tend to
consider that they value to report to the physiatrist rather
than disclosure for the clients. Because they do not haveauthority to practice of therapy. Therefore, occupational
therapists may entrust to physiatrist about disclosure. As

The Issue of “Physiatrist’s Prescriptions” in the
Practice of Occupational Therapy in Japan
Therapist belong to many types of organization. The
physiatrist supervises the therapists in the position ofgeneral manager. Fundamentally, occupational thapists
should evaluate, assess and make the plan as theprofession. However, some of the physiatrists often fulfill
a role, and prescribe to therapists. In that case, many oftherapists consider they should practice therapy withcomplying prescription. So,occupational therapists whopractice therapy for clients without consent consider theprescription is “absolute order” . Therefore, we consider
that they have a motive to practice therapy for the client
without consent (Figure 2).
We consider that the occupational therapists havemotive to comply strictly with prescription. In, thosecases, we are doubtful that the therapists originallyrespect the patient’s autonomy through the informed
consent. We cannot feel to therapists whose
professionalism and the standpoint of caregiver is for theclient. We lose a viewpoint as the employment having thenational qualification and consider that we must not meetfor an occupational therapist.

Intervention Planning on examination
Verification of the effects

General manager(Physiatrist)
Prescription

Head of a section(Chief therapist)

Clients (patients)

Evaluation?
Intervention Planning?

Therapy practiceOccupational therapists

Allegiance for physiatrist?

Figure 2: The Issues of Occupational Therapy in Japan

84

Eubios Journal of Asian and International Bioethics 22 (March 2012)a result, Therapists do not respect client’s autonomy(Figure 3).

Clients
Evaluation
andTherapyConsent Disclosure
Prescription

Therapist

Physiatrist
Figure 5. “The Way of Decision-making in the Practice ofOccupational Therapy”(n＝28)

ReportingFigure 3. The issue of informed consent in the practice ofoccupational therapy
The Clients hopes regarding Disclosure andDecision-making method about occupational therapy
We surveyed clients of occupational therapy in August
2009. The subjects asked were 95 clients who are
inpatients and outpatients in the hospital or facility for thethe elderly in Saga prefecture.The respondents were 28
clients. The question is “Which professions do you hope
to be informed about occupational therapy?” The manyclients answered, “Occupational therapist”, or “Therapist
and physician” (Figure4). We consider that the clients
hope to be informed by therapist rather than physician isimportant.
Reason of OT practce
Evaluation and Assessment
Treatment

12
14

5

9
8

2

17

Prognosis

7

Risk

7

Cost

9

7

4

13
8
13
8

What it takes to develop the prescription in thepractice of occupational therapy in JapanThe definition of occupational therapy is very different
between physiatrists and therapists. The Japanese
Association of Occupational Therapists has defined that
“Occupational therapy is to provide treatment,
supervision or care to those who have or may havephysical and/or mental disabilities, for the purpose ofgaining active life, through various occupations whichfacilitate, restorate or develop various functions”(TheJapanese Association of Occupational Therapists,1985).
Occupational therapists value to be enabling occupations
with the client’s own culture or environment.
On the other hand, Chino, physiatrists and the exchairpersonoftheJapanese
AssociationofRehabilitation Medicine has defined that, “Occupational
therapy is the practice of therapeutic exercise aimed to
improve range, strength, skilled motor behavior andendurance like creative occupation, as exemplified byfancywork and craft” (Chino,2009 p21). Physiatrists value
physical function. However, physiatrist’s definition is
unclearly specialty between occupational and physicaltherapy. Probably, the physiatrists do not understand thedefinition of occupational therapy that therapists definite.
However, therapists have trouble to promote
understanding toward physiatrists in definition ofoccupational therapy.

8
9Therapist

PhysicianClients
Consent? or not?

Therapist and Physician

Figure 4. “Which professions hope you to be informed
about occupational therapy?”(n＝28)
We indicate the result of the question “The Way ofDecision-making in the Practice of Occupational
Therapy”. Eleven clients answered “entrust withtherapist”. Nine clients answered “decided by one self”(Figure 5). From this result, some of the clients hope tosupport for the therapist by decision-making in thepractice occupational therapy at least.

Develop prescription through dialogue,
and disclosure to client
Therapists

dialogue

Making up intervention
planning based on
occupational therapy process

PhysicianAcceptation of planning
Information for therapists
about medication, risk factor ,life prognosis

Figure 6. Whole concept of appropriate prescription
system in the practice of occupational therapy

Eubios Journal of Asian and International Bioethics 22 (March 2012)
Occupational therapy requires a team approach. And,occupational therapists cannot practice therapy without
information about medication, risk factor and life
prognosis, for example. So, occupational therapists andphysiatrists have to hold a dialogue more and more. And,
they have to create mutual understanding. These things
can develop prescriptions, and can lead to more
appropriate “informed consent” (Figure 6).
We have two important points to develop theprescription in the practice of occupational therapy inJapan. One of the points is ethical education forregistered occupational therapists and occupational
therapy students. Second, occupational therapists shouldattempt to understand what is occupational therapy
through dialogue with physiatrists.
References
Chino N (1976) “Rihabiriteshon no Shoho ni Tsuite (The
Prescription in Rehabilitation Medicine)”, The Japanese
Journal of Rehabilitation Medicine, Vol.13, No.1, pp.4-5.
Chino N (2009) “Rihabiriteshon Igaku souron (GeneralStatement of Rehabilitation Medicine)” ,Chino N, ed. Gendai
Rihabiriteshon Igaku (Modern Text Book of Rehabilitation
Medicine) Third edition, Kanahara-Syuppan, pp.1-25.
Hattori I (1984a) “Syoho, Iraisho no Kakikata（Writing Methodof Prescription or Referral）”, Hattori I, ed. Rihabiriteshonigaku Zensyo (Encyclopedia of Medical Rehabilitation
technique) Second Edition , Igaku-syoin, pp.754-75.
Hattori I (1984b) “Igakuteki-rihabiriteshon no unei to kanri(governance of Medical Rehabiritation)”, Hattori I, ed.
Rihabiriteshon-igaku Zensyo (Encyclopedia of Medical
Rehabilitation technique) Second Edition , Igaku-syoin,
pp.69-88.
Kamakura N, Ueda S, Matsumura S, Yatani R (1971) “Zadankai
PT ・ OT no syoho wo megutte (Discussion meeting,Concerning of Prescriptions of Physical Therapy andOccupational Therapy)”, Japanese Journal of Physical
Therapy and Occupational Therapy, Vol.7, No.6, pp.401-10.
Licht S (1948) “The prescription of occupational therapy”. New
York State Journal of Medicine. Vol.48, No.9, pp.1032-4.
Martin, (1971) “Prescribing Physical and Occupational
Therapy”, Kottke FJ, et al, ed. Krusen's Handbook of Physical
Medicine and Rehabilitation Fourth edition, Saunders,
pp.510-18.
Mazer J, Goodrich W (1958) “The Prescription: an
Anachronistic Procedure in Psychiatric Occupational
Therapy”. The American Journal of Occupational Therapy .
Vol.12, No.4, Part1, pp.165-70.
Ogishima H(1980) Rihabiriteshon syohogaku (Rehabilitation
Prescription) Second Edition, Ishiyaku-syuppan.
Rusk HA(1977) Rehabilitation Medicine Fourth Edition, Mosby.
Shinsya N, Ishigami S (2010) “Goal-oriented Rehabilitation
Directed by Physiatrists does Change Rehabilitation
Outcomes of Patients”. Journal of Clinical Rehabilitation,
Vol.19,No.8, pp.722-7.
Spencer WA(1969) “Changes in methods and relationships
necessary within rehabilitation” ， Archives of Physical
Medicine and Rehabilitation, Vol.50 No.10, pp.566-80.
Terayama K(1976) “Sagyo-ryoho to Syoho ( Occupational
therapy and Prescription)” , The Japanese Journal of
Rehabilitation Medicine, Vol.13, No.1, p7.
Terayama K (1990) “Anketo-chosa to Iken wo Yonde, OT no
Tachiba kara (Comment on the Questionnaire andConsideration from Standpoint of Occupational Therapist)”
General Rehabilitation, Vol.18, No.4, p283.
World Federation of Occupational Therapists (2011) “Japanese
Association of Occupational Therapists”, Definitions of85

Occupational Therapy from Member Organization Update30082011”, p25, Retrieved January 31,2012,
from http://www.wfot.org/ResourceCentre.aspx
Ueda S (1992) Rehabiritation Igaku no Sekai ( The world of
Rehabilitation Medicine ). Miwa-shoten.
Yatani R(1990) “Anketo-tyosa to Iken wo Yonde, OT no
Tachiba kara (Comment on the Questionnaire andConsideration from Standpoint of Occupational Therapist)”
General Rehabilitation, Vol.18, No.4, pp.282-3.
Yamano K(2011) “The Behavior of Occupational Therapists
whose Clients who do not Consent to Occupational Therapy”
The Journal of Japanese Association of Occupational
Therapists. Vol.30, No.5, pp.631-4.

The Present State of Commercial
Surrogacy in India and the
Ethical Assessment of Physician
in Charge Dr. Nayna
Patel―Ethical Researchconcerning Indian Reproductive
Medicine, Especially Commercial
Surrogacy- Masayuki Kodama, Ph.D.
Director of the International Exchange and Language Education
Center, National Institute of Fitness and Sports in Kanoya, 1
Shiromizu-cho, Kanoya, Kagoshima, Japan, 891-2393
Email: kodama@nifs-k.ac.jp

Abstract
India is a very important hub for medical tourism. In
India, as is the case in Thailand, Singapore andMalaysia, the state exerts all of its powers in order toattract medical tourists. In India, hospitals with thenewest medical facilities offer state of the art medical
technologies to their patients in a variety of medical
disciplines. The high levels of Assisted Reproductive
Technology (ART) and commercial surrogacy are
powerful primers to foreign infertility patients. The yearly
increasing amount of money in foreign currencies flowing
into India by orders for commercial surrogacy fromforeign infertility patients in developed countries, as of2009, has been estimated at 500 million dollars. India’scommercial surrogacy is the honor student of medical
tourism second only to the top foreign currency earner,
the IT industry.
Backed by the Indian government’s official sanctionthat strongly promotes medical tourism as a national
policy, gynecologist Dr. Nayna Patel is currently
performing reproductive medical activities in Anand, thebirthplace of surrogacy in India. In this paper, according
to the research results of a three-layer structured
analysis of India’s reproductive medical (surrogacy)
ethics, I will introduce the present state of surrogacy inIndia as experienced by the world renowned surrogacy
expert Dr. Patel (layer 1), and I will investigate her ethicalassessment (layer 2) as well as Hinduism’s view ofreproductive technology supporting Dr. Patel’s ethicalassessment (layer 3).

86

Eubios Journal of Asian and International Bioethics 22 (March 2012)

1. Analysis of the present state of surrogacy in India
based on Dr. Nayna Patel’s experience (layer 1): Dr.
Nayna Patel is the founder of the Akanksha Clinic in
Anand in the province of Gujarat. From 2003 until June
2010, the number of surrogate mothers coming out of thisclinic exceeded 300. The first patient for whom Dr. Patel
performed surrogacy was a woman born without a uterus(Rokitansky-Küster-Hauser syndrome). Since then, andto February 2011, Dr. Patel has achieved more than 250
successful cases of surrogacy and more than 330
children have been born.
2. Analysis of Dr. Patel’s ethical assessment (layer 2)
as well as Hinduism’s view of reproductive
technology supporting this ethical assessment (layer
3): In Indian society where the Hinduism based caste
system still strongly exits, the escape road out of poverty
lies with education. However, to many females born inthe class of the untouchables, the Harijan, the road ofeducation is closed. Consequently, It appears to womenof impoverished families that the big money industry ofsurrogacy is an attractive way to make money. But this is
not the only reason. To the Indian reserve corps ofsurrogate mothers, surrogacy is also a fulfilling job as itallows them to get the feelings of fulfillment that
accompany pregnancy. Dr. Patel relates, “To bothpatients who have not been blessed with a child and to‘womb suppliers’ who are suffering from poverty,
surrogacy performed at the Akanksha Clinic is a win-win
situation.”
Moreover, as a fortunate fact for Indian women of
impoverished families, in Hinduism, to which 80% of the
1.2 billion Indian population adhere, an understanding
towards assisted reproductive technology is very high. In
Hindu mythology we encounter transmissions that remind
us of modern assisted reproductive medical technology.
For example, there is a story in which a female deity
conceives and gives birth by the injection of a maledeity’s sperm (artificial insemination), and a story where afetus is born from another woman’s womb (surrogacy). In
the Hindu nation of India, where rebirth (the revolving
wheel of life) and karma (cause and retribution, thenaturalconsequences
of
one’s
own
foolishdeeds/behavior/action) form a basic set, common
religious ceremonies for the gods Shiva and Mahadevi
coexist with assisted reproductive medical technology
without colliding over contradictions.
Keywords: Commercial Surrogacy, Medical Tourism,
Art, Nayna Patel, Ethics
Introduction
India is a very important hub for medical tourism. In
India, as is the case in Thailand, Singapore andMalaysia, the state exerts all of its powers to attract
medical tourists. In India, hospitals equipped with thenewest medical facilities are offering patients cuttingedge medical technologies in various medical disciplines.
Particularly the high levels of Assisted Reproductive
Technology (ART) and commercial surrogacy are strong
primers for foreign infertility patients. India’s foreign
currency profits, stimulated by yearly increases ofcommercial surrogacy orders from foreign infertility
patients in developed countries, as of 2009, have been

16

estimated at a half-billion dollars . India’s commercial
surrogacy is the honor student of medical tourism second
only to the top foreign currency earner, the IT industry.
17
The three major strongholds of Indian surrogacy are
Mumbai, Delhi, and Anand in the province of Gujarat.
Other places where surrogacy is performed in the country
include Bangalore, Poona, Chennai, Ahmadabad,
Hyderabad and Calcutta.
Dr. Nayna Patel, a world renowned physician educatedin the US with extensive training in reproductive medicine
and experience in surrogacy, performs reproductive
medical activities in Anand, the birthplace of Indiansurrogacy, backed by the authorization from the Indian
government that strongly promotes medical tourism as anational policy, This is the doctor who lives in the “city ofsurrogate mothers” and who has overnight become
known throughout the United States as the “queen of
surrogacy’”as a result of an opportunity, in October 2007,
to appear on the popular and long-lived American talkshow The Oprah Winfrey Show (8 September 1986 – 9
September 2011).
In this paper, we introduce the present state ofsurrogacy in India (layer 1) as experienced by renowned
surrogacy expert Dr. Nayna Patel, and probe her ethicalassessment (layer 2) as well as Hinduism’s view ofreproductive
technology supporting
thisethicalassessment (layer 3).
The present state of commercial surrogacy in India(layer 1)(1)
The Indian government’s stimulation policy for
medical tourism and the revival of commercial surrogacy
In 2002, the Indian government made a declaration of
stimulating medical tourism by offering experienced
physicians with advanced medical techniques as
exchange students to English speaking countries, thelatest in medical facilities, low costs and the simple
procedures which are attentive to the foreign patients. In
2004, the Indian government began to issue medical
visas to medical tourists.
In India, where the government perceives medical
tourism as an effective means to obtain foreign
currencies, the Indian Council of Medical Research(below; ICMR), published the Statement of SpecificPrinciples for Assisted Reproductive Technologies, 2000
(revised in 2006). In the original statement it was unclear
whether commercial surrogacy would be accepted or
declined, but, two years later, in the National Guidelines
for the Accreditation, Supervision and Regulation of ART
clinics in India, in 2002 the ICMR prompted an ongoing
public debate concerning this guideline, in cooperation
with the Indian National Academy of Medical Science(below; INAMS). In India, where “medical tourism
18
towards India is increasing yearly by 30% ” as a positive
16 16

Indian surrogacy is now a half-billion dollar industry. （Outsourcing Pregnancy [The Daily Beast: October 11, 2009]）
ICMR estimates that India’s foreign currency profits willamount to 6 billion dollars in 2015.
17
Usha Rengachary Smerdon: Crossing Bodies, Crossing
Borders: International Surrogacy between the United Statesand India, 2008 . http://www.ethicanet.org/Smerdon.pdf
18
medical tourism to India is growing by 30% a year （CBCNews Online : June 18, 2004）

Eubios Journal of Asian and International Bioethics 22 (March 2012)87

result of the “Indian national health policy’s declarationthat foreign patients medical treatment is a legitimate
19
form of ‘export’ ” (CBC News Online: June 18, 2004),
the performance of gestational surrogacy began in 2003,
i.e. the performance of what is called the borrowed womb
(IVF surrogacy). In 2005, three years after effectuating
the public debate, the ICMR and INAMS published arevised (2005) edition of the 2002 guideline.
In the wake of a situation that occurred in 2008
(subsequently resolved through supplementary legal
action), in which the newborn child of a Japanese male
physician who had utilized surrogacy in India was bornstateless as the result of the pre-birth divorce of his
father, the Indian Ministry of Health & Family Welfare(below; MHFW), in cooperation with the ICMR, hastily
effected the Assisted Reproductive Technologies(Regulation) Bill, 2008; the 2008 ART (Regulation) Bill bywhich the legal position of surrogate children has now
been established. The document that formed thefoundation for this bill was the Assisted Reproductive
Technologies(Regulation)Bill, 2006: the 2006 ART(Regulation) Bill published by the Republic Interest Legal
Support and Research Center. The provisions added to
the 2008 ART (Regulation) Bill from the perspective ofguaranteeing the welfare of surrogate children with the
purpose of prevention are as follows.
“1. A guardian will be attached to the surrogate mother(7.34.(19))
2. The child will belong to the surrogacy requester even
if this person divorces before the child is born”(7.35.(4))
Through the enactment of this bill, although thelegitimacy of remuneration for the surrogate mother isrecognized(7.34.(3)), the surrogate mother’s parental
rights towards the child are completely relinquished(7.34.(4)). Furthermore, this bill has made it mandatory
for the name of the genetic parent(s) (7.34.(10)) as wellas the full name of the surrogacy requester to be written
on the child’s birth certificate.
However, in 2009, after the enactment of the2008(Regulation) Bill, India witnessed a recurrence oftrouble concerning the nationalities of surrogate children.
The surrogate twins of a patient holding the German
nationality, in whose home country surrogacy is illegal,
were denied citizenship in both Germany and India andbecame stateless. Through the Indian government’s
March 2010 recognition of the twins as the adopted
children of the German national who made the surrogacy
request, the German government granted the twins entry
into the country and citizenship. With this case as a
stepping stone, and from the viewpoint that the Indian
government must absolutely guarantee the welfare ofsurrogate children, the 2008 ART (Regulation) Bill wasamended to form
the Assisted Reproductive
Technologies(Regulation)Bill, 2010; the 2010 ART(Regulation) Bill. The new provisions incorporated in the2010 (Regulation) Bill are as follows.
1.
Foreigners must present documents in evidenceof the legitimacy of surrogacy in their home country andproof that children will be granted citizenship there(7.34.(19))
2.
Children cannot be granted Indian nationality(7.35.(8))
3.
In case children are not taken to their homecountries within one month following their birth, they will
be granted Indian citizenship (7.34.(19))
4.
In case the surrogacy requester cannot claim thechild, the guardian is allowed to present the child for
adoption (7.34.(19))
5.
The surrogate mother is responsible for thechild’s health until the child is handed over (7.34.(23))
6.
The requester is responsible for the surrogate
mother’s health until the child is handed over (7.34.(24))
Because of a lot of medical tourists visiting India fromabroad, in today’s India, as the result of having been on
the receiving end of some unfavorable circumstances,
together with surrogate mothers from the lower classes,
surrogate mothers with high academic qualifications fromthe middle classes are even appearing on the scene.
Moreover, surrogacy repeaters, i.e. professionalsurrogate mothers, are also emerging. However, in
response, the 2008 ART (Regulation) Bill(7.34.(5))
stipulated that surrogate mothers had to be over 21 yearsof age and under 45, and that the maximum number oftimes the surrogate mother could challenge surrogacy in
her lifetime was two with those numbers changing again
in the 2010 ART (Regulation) Bill(7.34.(5)),
whichstipulated that the surrogate mother had to be over 21
years of age and under 35, and that the permitted
number of times the surrogate mother could give birth toa child was three.

19

20

India's National Health Policy declares that treatment offoreign patients is legally an "export"（ibid）(2)
The present state of surrogacy in India as
experienced by Dr. Nayna Patel
Dr. Nayna Patel is the founder of the Akanksha Clinic in
Anand, Gujarat, the province that has brought forth
20
Mahatma Gandhi. From 2003 to June 2010, this clinic
treated more than 300 surrogate mothers with, according
to Miho Hirai’s research, the first patient to receive
surrogacy treatment by Dr. Patel in 2003 a woman born
without a uterus (Rokitansky-Küster-Hauser syndrome).
Since that time, and until February 2011, Dr. Patel
achieved more than 250 successful surrogate births withover 330 conceptions. As of February 2011, Dr. Patel
was managing two exclusive houses for surrogate
mothers, surrogacy houses, at a location approximately 5
minutes by car from the Akanksha Clinic, where sheallows about 60 surrogate mothers to live temporarily.
Anand is a “milk town” where a population of 300.000
Hindu believers coexists with holy cows, but where theabout 6 million people from Gujarat who live abroad(comprising just under 30% of all 20 million Indian
nationals living abroad) can combine their homecomingwith a visit to the infertility clinic. Anand, dotted withinfertility clinics equipped with the newest reproductive
medical facilities, has become a very important Mecca for
India’s medical tourism.

‘Google Baby’Follows Birth Outsourced To India [NPR: June15, 2010]

88

Eubios Journal of Asian and International Bioethics 22 (March 2012)(3)
Dr. Nayna Patel’s clients
Dr. Nayna Patel’s clients requesting surrogacy are notjust the wealthy class of Indian people holding Indian
nationality living inside India as well as abroad, but alsoWesterners (Americans, British, Canadians, Germans,
French, Israeli, Australians) and Asians (Koreans,
Taiwanese, Japanese), totaling more than 30
nationalities. In the Akanksha Clinic, the surrogacy
program is restricted to couples (with the exception ofhomosexual couples) who are not able to give birth tochildren for medical reasons.
India’s surrogacy clients before the enactment of the2008 ART (Regulation) Bill were not only opposite sex
couples without children, but also many same-sex
couples from western countries. The clear specification inthis 2008 bill of the possibility for singles, unmarried
couples as well as same-sex couples to request
surrogacy (7.32.(1)) was indicative, however, of the21
difficulties existing inside India, where a law exists(section 377 of the Indian Penal Code)that prohibits
homosexuality, with the possibility for homosexuals, as
they had done until 2008, to openly make use of
reproductive medical tourism. With the enactment of the2010 ART (Regulation Bill), homosexuals are no longer
able to use surrogacy in India.
(4)
The costs of surrogacy
In the practice of surrogacy, Dr. Nayna Patel isconsciously making it her policy to use the expression“donating a womb” instead of the expression “renting awomb”. From the avoidance of businesslike terms in her
daily speech, careful and thoughtful attention can beinferred to her intentions to avoid any undesirable discord
accompanying the delicate medical service of surrogacy.
In the event of pregnancy and birth by a surrogate
mother, the surrogacy requester pays a remuneration of
approximately 700.000 yen. In case of twins being born,
25% is added to this amount. Together with a threemonth remuneration payment, during the pregnancy
period the surrogate mother receives living expenses ona monthly basis in the amount of 10.000 yen to increase
the chance that a healthy child is born. As has beenstated above, the 2010 ART (Regulation) Bill stipulates
that the requester is responsible for the surrogate
mother’s health until the child is handed over (legal
obligation(7.34.(23)) to protect the surrogate mother’s
rights), and that the surrogate mother is responsible forthe child’s health until it is handed over to the requester(legal obligation(7.34.(24)) to protect the child’s rights).
However, in the event that pregnancy and birth do notoccur, the surrogate mother receives very little
remuneration.
According to Miho Hirai’s research, the price for
consultation at Baby for All, which is a surrogacy
consulting company (founded in August 2009 in
California, United States) associated with the Akanksha
Clinic, is 430.000 yen and the cost for surrogacy at thisclinic 2.300.000 yen. The clinic receives 1.600.000 yen
for hospitalization costs and infertility treatment charges,
after 700.000 yen has been paid to the surrogate mother.
If a surrogacy requester from Japan were to sign acontract directly with this clinic, surrogacy costs would
amount to approximately 2 to 2.5 million yen, or
somewhere in the area of 3 million yen with the inclusionof expenses like travel. However, if a surrogacy
intermediary – The Nevada Center for Reproductive
Medicine (Egg-cell Service/Surrogate Mother Birth
Information Center, Tokyo, Chiyoda, representative Yuki
Sumi) or IVFA (Tokyo, Shibuya, representative Yukie
Rowen) – were to mediate, in case of theseorganizations, a mediation fee of 7 million yen and 6.8
million yen respectively would have to be added. In
comparison with 15 million yen that would be required for
infertility treatment in the US, 6 to 8 million yen forsurrogacy, in addition to such fee as mediation andtravel, does not seem overly expensive, with 2/3 (10million yen) to 1/5 (3 million yen) that of the US, India isclearly a very attractive option for surrogacy requesters.
Incidentally, the 2010 ART (Regulation) Bill (7.34.(13))
states that “the surrogate mother may not also serve as
egg-cell donor”, thus prohibiting artificial fertilization
surrogacy (intrauterine insemination; IUI), i.e. traditionalsurrogacy in which both uterus and egg-cell are offeredby the same person, but in vitro fertilization (IVF)
surrogacy using an egg-cell that is offered by a third
22
party (gestational surrogacy) is permitted.
2 The ethical assessment of Dr. Nayna Patel, thephysician in charge of commercial surrogacy in India(1)
Dr. Nayna Patel’s ethical assessment (layer 2)
The largest number of Indian women hoping forsurrogacy come from impoverished families belonging to
the caste of the untouchables, the Harijan. In foreign
developed countries where information concerning
surrogacy sanctioned by the Indian government is very
poor, intellectuals in the media condemn surrogacy
tourism by rich but infertile married couples fromdeveloped countries as the physical and psychological
exploitation of impoverished Indian women, or as indirect
prostitution. On one side of the argument, within India
itself, the Manji Yamada incident (see below) was
denunciated as human trafficking by one of Jaipore’s
welfare groups, Sati (truth).
Based on the above described state of affairs in India,
Dr. Nayna Patel displays the following altruistic outlook
on gestational surrogacy performed at the Ananksha
Clinic in Anand, and which is often exposed to criticalcomments.
1)“How can people say that what women do of
their own volition is exploitation? Although European
people are also participating in surrogacy in America, I
have never heard anyone say that European people are
exploiting American women. Why is it called
23
exploitation
when it becomes an Indian issue?”
Surrogacy that is performed at the Ananksha Clinic is a
win-win situation for both the requesters who do not have21

“Indian IVF bill stop gay couple surrogacy.” Andhra News net
2010/04/26, “Surrogacy still not an option for Indian gay,lesbian couples.” The Times of India 2010/05/27, “No moresurrogate option for same sex couples in India.” My Bangalore,
2010.

22

For example, an egg-cell donor was paid Rs 20.000 for theprocess, which takes four weeks. Cf. Time for the brown baby
boom [Hindustan Times: July 21, 2009]23
India’s Baby Factory(SBS Dateline: Feb 22, 2009 )Eubios Journal of Asian and International Bioethics 22 (March 2012)
children and the “uterus donator” suffering from poverty.
“We’ve started a project called Surrogacy Trust thatoffers educational opportunities to children of surrogate
mothers. They are taught computers and sewing skills forfree.” “Surrogate mothers are not killing anyone. They do
not violate the law, and they do not act immorally. They
can allow their children to have an education and they
can also buy a house for their families. Moreover, they
are aiding married couples without children. Where is theharm in that?”2)
However, it is necessary to lecture on protective
measures so that women from impoverished families
hoping for surrogacy are not coerced into surrogacy
against their will. Here, the doctor expounds on theimportance of maintaining a linear counseling system andof surrogacy procedures for primi(multi)parae under theage of 35 from impoverished families who hope forsurrogacy. If substantial counseling is rendered, thecoercion of economically weak women into surrogacy bymembers of their family (husband, in-laws) scheming toseize the remuneration for surrogacy or by third parties(relatives, malignant brokers) can be avoided.
Compensation for surrogacy, based on spontaneity, is
set aside as a construction fund for a new house or as achildren’s education fund, and sometimes for thepurchase of business necessities for the husband (amotorized rickshaw, for example).
3)
Surrogate mothers who have signed a contract
move into the surrogacy house and prepare for birth.
Based on the guidance of a physician who supervises
surrogate motherhood screening (aptitude examination),
nutrition, physical condition, and so on, nurses andnutrition experts look after the pregnant women who livein the house. Surrogate mothers have board and lodging
inside the hygienic confines of the surrogacy house forthree months before and after birth, where contact with24
their family is allowed. Amrita Pande , who has done
research in the field, tells about how to the pregnant
women the restricted but sanitary space in which they
live does not appear to an uncomfortable place, and,furthermore, that by being hospitalized and giving birth
here surrogacy can be performed without having toreveal it to their relatives and neighborhood.
It is important to have a substantial counseling system
in which the English written guidelines are precisely
explained to the surrogate mothers under contract that
include illiterate women from impoverished families. “Is it
so that because surrogate mothers are uneducated theycannot decide for themselves?”, Dr. Nyna Patel shotback at those who regarded the illiterate surrogate
mothers as children.
(2) The standpoint of the Indian women who volunteer assurrogate mothers and Hinduism’s view of reproductive
technology supporting Dr. Nayna Patel’s ethicalassessment (layer 3)
What would the Indian women who volunteer assurrogate mothers think about the requesters from India
and abroad who make use of surrogacy tourism

sanctioned by the Indian government and commercial
surrogacy? Are India’s surrogate mothers, whose bodies
are governed by their husbands or by third parties within
the patriarchal system of Indian society, the victims of
exploitation? Or, is surrogacy reproductive (clinical) laborbased on the free choice of impoverished Indian women?
For a better understanding an on-scene verification ofIndia’s surrogacy is required.
In India’s society where a deeply rooted caste system
based on Hinduism still exists, education is the escaperoad out of poverty. However, to many of the women in
India’s caste of untouchables, that road of education isclosed. Under such circumstances, for women of
impoverished families, surrogacy, which earns them a lot
25
of money, appears to be an attractive way to get
income. Furthermore, for India’s reserve army ofsurrogate mothers, surrogacy appears as a fulfilling job
which allows them a taste of the feelings of happinessaccompanying pregnancy.
Moreover, as a fortunate reality for Indian women of
impoverished families, Hinduism, to which 80% of India’s
1.2 billion population adhere, is very understanding
towards assisted reproductive technology. In Hindu
mythology we come across transmissions reminding usof modern assisted reproductive technology. For
example, there is the story of a female deity whoconceives by the injection of a male deity’s sperm(artificial insemination), and the story in which a fetus isborn from another woman’s womb (surrogacy). The
former is in Hindu mythology concerning the nativity of
Skanda and the latter is in Hindu mythology concerning
the nativity of Kṛṣṇa. In the Hindu nation of India whererebirth (the revolving wheel of life) and karma (cause andretribution, the natural consequences of one’s own
foolish deeds/behavior/action) form a basic set, common
religious ceremonies for the gods Shiva and Mahadevi
coexist with assisted reproductive medical technology
without colliding over contradictions.
(3) The Indian government’s standpoint on ethical issues
concomitant with surrogacy
What would the stance of the Indian government be,that has sanctioned Dr. Patel’s reproductive technology,
against the rumored apprehensions in the world?
1)
Countermeasures taken against the issue of thestatelessness of a surrogate child as represented by the
problems resulting from the repatriation of Manji, a girlborn on July 25, 2008, the incident in which a female
fetus became temporarily stateless after being born outof a fertilized embryo obtained by the insemination of an
egg-cell donated by an anonymous Nepalese woman toa Japanese physician, and then transference to an Indiansurrogate mother by Dr. Nayna Patel, and again, in the26
instance
where the parental rights of Frenchhomosexual Raymond Suoto concerning a surrogate
child born on April 6, 2010 in Mumbai were notrecognized in his home country of France where
surrogacy is prohibited.
25

24

Amrita Pande:Commercial Surrogate Mothering in India ：Nine Months of Labor? A quest for alternative sociology 3; 7187, 2008.

89

Pande Amrita, 2010 “Commercial Surrogacy in India:
Manufacturing a Perfect ‘Mother-Worker’”, Signs: Journal of
Women in Culture and Society, Vol 35, No. 4.
26
Surrogacy woes: India-born baby in French foster care [DNA:Jul 27, 2010]

90

Eubios Journal of Asian and International Bioethics 22 (March 2012)

Instigated by the incident of Manji Yamada, the child ofa Japanese physician – the Indian government issued a
travel certificate permitting Manji (Indian name) to departfrom India as a stateless person and the Japanese
government issued an entry visa on October 27, 2008 –the Indian government enacted the 2010 ART(Regulation) Bill that established the legal position ofsurrogate children born in India. As stated previously,with the enactment of this bill (7.34.(19)), foreign
requesters making use of Indian government sanctioned
surrogacy tourism are obliged to present two kinds of
documents.

A certificate stating that surrogacy is legitimate in
one’s home country
A certificate stating that one’s home country will
grant citizenship to the surrogate child
2)
Countermeasures in case a surrogate mothergives birth to a seriously handicapped child and therequester refuses to accept the child.
Legal compensation in such an event is as follows.
A guardian is attached to the surrogate mother(7.34.(19)). In the unlikely event that a requester cannot
accept a surrogate child, the guardian is able to present
the child for adoption (as above). In the event that arequester is not able to take the child with him/her tohis/her home country within one month after the child isborn, the Indian government can grant the child Indian
citizenship (as above).
(4)
A request for the Indian government
According to Unicef’s 2009 version of the White Paper
on Children of the World, in 2005 approximately 536.000
women around the world died during pregnancy orchildbirth. Of this number, 117.000 expectant and nursing
mothers died in India. If we estimate that in India roughly
27 million people are born each year, then this meansthat of every 230 expectant and nursing mothers, one
mother dies. Compared to Japan’s 39 deaths amongexpectant and nursing mothers in 2005 (5.7 deaths
among expectant and nursing mothers per 100.000
births), childbirth in India is, as the numbers show, agreat and life threatening feat. Dr. Nayna Patel relates

that at reproductive treatment clinics equipped withmodern medical facilities, health damages do not occur
so frequently. However, it is necessary that the surrogacy
sanctioning
governmentofIndia
implements
investigations into the actual condition of surrogacy
related health damages throughout India.

Conferences
For a list of some ethics meetings in Asia and Pacific:
http://eubios.info/conferences
EJAIB Editor: Darryl Macer
Associate Editors
Jayapaul Azariah (All India Bioethics Association, India),
Masahiro Morioka (Osaka Prefectural University, Japan).
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Angeles Tan Alora (Philippines), Atsushi Asai
(Japan), Alireza Bagheri (Iran), Gerhold Becker(Germany), Napat Chaipraditkul (Thailand), Shamima
Lasker (Bangladesh), Minakshi Bhardwaj (UK), ChristianByk (IALES; France), Ken Daniels (New Zealand),Leonardo de Castro (The Philippines), Ole Doering(Germany), Amarbayasgalan Dorjderem (Mongolia),
Thomas Gionis (USA), Dena Hsin (Taiwan), Sawa Kato
(Japan), Rihito Kimura (Japan), Abby Lippman (Canada),
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Noritoshi Tanida (Japan), Ananya Tritipthumrongchok(Thailand), Yanguang Wang (China), Daniel Wikler(USA), Jeong Ro Yoon (Republic of Korea).
EJAIB Editorial address: Prof. Darryl Macer, Director,
Eubios Ethics Institue, c/o Center for Ethics of Scienceand Technology, Chulalungkorn University, Faculty ofArts, Chulalungkorn University, Bangkok 10330,
THAILAND
Email: darryl@eubios.inf

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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
st
Bioethics and the Impact of Human Genome Research in the 21 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
NZ$50
st
Bioethics in Asia in the 21 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
NZ$50
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
NZ$50
A Cross Cultural Introduction to Bioethics
2006, 300pp. (A4)
Editor: Darryl Macer
Cost: US$35 Euro35 UK£20 NZ$40 A$38 C$40 ¥3000
NZ$50
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Eubios Journal of Asian and International Bioethics 22 (March 2012)

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