Eubios Journal of Asian andInternational Bioethics
EJAIB Vol 19 (2) March 2009ISSN 1173-2571

Copyright ©2009 Eubios Ethics Institute (All rights reserved, for commercial reproductions).
Eubios Ethics Institute World Wide Web: www.eubios.info/index.htm
Official Journal of the Asian Bioethics Association (ABA)

Contents

page

Editorial: Universality of Bioethics
33
Institutional Review Boards, Worldwide (IRBs)
35- Jayapaul Azariah
Contextualizing Bioethics: The UNESCO Declaration
on Bioethics and Human Rights and observations
about Filipino Bioethics
42- Lukas Kaelin
Aesthetics in Ethics: Narrative and Theoretical
Dimensions of Moral Evaluation
47- Paolo Marino Cattorini
Perception of Physicians and Medical Students oncommon Ethical Dilemmas in a Pakistani
Medical Institute53- Bushra Khizar and Mobeen Iqbal
Altruism: An Ethical Resource for Dealing with
HIV & AIDS55
- Helen Kunbi Labeodan
Evolution of altruism
58- K. K. Verma and Suresh C. Sharma
The rare plants' lamentation
59- Bing H. Tang
Arts Bioethics Network (ABN)60- Chamu Kuppuswamy and Paul Ulhas Macneill
Human Cloning: Prospects and Challenges in the AsiaPacific Region
61- Shamima Parvin Lasker
Other information and conferences
63
Order form
64
Editorial address:
Prof. Darryl Macer, RUSHSAP, UNESCO Bangkok,
920 Sukhumvit Rd, Prakanong, Bangkok 10110, THAILAND
Fax: Int+66-2-664-3772
Email: d.macer@unesco.org

The deadline for the May 2009 issue is 1 May, 2009.

Original papers, commentaries,
news and reviews should besubmitted in electronic form to
the editor.

Editorial: Universality of Bioethics
One of the recurrent themes in international
discussions of bioethics, and in Asian bioethics, isthe universality of descriptions and prescriptions ofbioethics. This issue of EJAIB includes a series of
papers which discuss that theme.
One of the common institutional structures tomake ethical decisions is a bioethics committee,
and in the first paper Jayapaul Azariah makes areview of the situation of Institutional Review Boards(IRBs) globally and in India. The data he uses isbased on the USA OHRP-approved IRBs, which is
updated on-line. There have been debates about
the way to recognize IRBs, and there function, butthey are only one model of bioethics committee.
There are several alternative models of ethics
committees, and UNESCO in its Assisting Bioethics
Committees (ABCs) program is aiding countries
who request assistance to establish national policy
making bioethics committees. These have a
different function to IRBs (See a series of books
availableindifferent
languages
fromwww.unesco.org/bioethics).
The case studies discussed in India include YRG
Care Ethics Committee, an AIDS relatedorganization. AIDS has been a catalyst for reflection
on bioethics, in a similar way to genetic technology
was. In another paper in this volume AIDS and HIV
are linked to the altruism. Altruism itself is a basis
for beneficence, which some, including myself,consider to be the most important principle ofbioethics.
The second paper in this issue is on“Contextualizing
Bioethics:
The
UNESCO
Declaration on Bioethics and Human Rights andobservations about Filipino Bioethics” by Lukas
Kaelin. This paper discusses some aspects of the
UDBHR, though focusing on the principalism implicitin the UDBHR. As a comment, which applies tomany analyses of the UDBHR, one first need toconsider whether UDBHR is only a prescriptive text,
or whether it is also a descriptive text. The context

34

Eubios Journal of Asian and International Bioethics 19 (March 2009)of the UDBHR was that it was a UNESCO
document approved by member countries, however,the correct title is the Universal Declaration on
Bioethics and Human Rights (UDBHR). While
many see it as a UNESCO document, the official
title is UDBHR. UNESCO is a secretariat to member
countries, so the Declaration is belonging tocountries not to UNESCO itself. Therefore the issue
is really how to compare state-level bioethics withthe cultural realities of different societies.
In the paper there is absence of referral to the
UDBHR article 12 accepting the importance of
cultural diversity and pluralism, nor referral to theConvention on Cultural Diversity which UNESCO
General Conference accepted at the same time as
the UDBHR. A Convention can become legallybinding when ratified, unlike a Declaration. All thearticles in the UDBHR provide a framework forcommon dialogue and discussion on bioethics,
among different cultures. From this framework our
dialogues can become fruitful.
That being said however, there are different
frameworks besides principalism on which bioethics
can be constructed. However, we can see theseframeworks not only in the Philippines, or other Asiaand pacific communities, but also within so-called
Western societies as well. The UDBHR does imply
principalism, because it has been a useful languagefor discussion of bioethics and for implementation ofpolicy, and because every state agreed to thatframework. Also the common legal framework ofprotection of human rights, is a starting point thatcan be used in discussing the universality of ethicalrelationships between humans and others. This
does not mean that we should ignore otherapproaches to ethical discourse however.
The next paper, “Aesthetics in Ethics: Narrative
and Theoretical Dimensions of Moral Evaluation”,
by Paolo Marino Cattorini, is exploring narratives inbioethics discussions. This is seen around the world
also, and in a sense continues the discussions of
the universality of human experience. The
comparative analysis of narratives is the basis fordescriptive bioethics, and there is much left todiscover.
The next paper looks at the development of ethics
education in Pakistan, with “Perception of
Physicians and Medical Students on common
Ethical Dilemmas in a Pakistani Medical Institute”,
by Bushra Khizar and Mobeen Iqbal. There is aneed for education in ethics. This leaves us with aquestion of what to teach. One of the recent
developments is the Core Curriculum on
Bioethics developed by UNESCO, which adopts a
series of values to be taught in a core course basedon what is accepted in the UDBHR. UNESCO would
like to enter into partnerships, and develop MOUs
with any institution that would like to trial the Core
Curriculum. Please write to me if you are in Asia-

Pacific region as we would like to trial out thecourse goals. The materials are still being enriched,
and a range of case studies and other teachingmaterial are available on UNESCO Bangkok andParis websites (and in GEObs database 6).
The paper from Nigeria on “Altruism: An EthicalResource for Dealing with HIV and AIDS”, by Helen
Kunbi Labeodan, is linked to “Evolution of altruism”
by K. K. Verma and Suresh C. Sharma. Altruism
has biological, social and spiritual origins. Whereverit came from however altruism and social
relationships certainly are central to bioethics.
There is a poem with an ecocentric angle, “Therare plants' lamentation” by Bing Tang, prior to a
description of the IAB Arts Bioethics Network (ABN).
Finally a paper from Bangladesh on “Human
Cloning: Prospects and Challenges in the AsiaPacific Region” by Shamima Parvin Lasker.
Although it can be said that we need to deal with thechallenges of social responsibility in bioethics when
faced with the high death rates of people across theworld, the issue of cloning and ES cell research is
one which shows how governance models adopted
in each country are diverse. Even if we may have
universality at some level, the right of each country
to make policies to respond to these issues in theirown way is central to our modern international
governance structure. Cloning debates in the UN
General Assembly led to a Declaration adopted withsplit opinions, which is in marked contrast to theunanimous agreement with the UDBHR.
This editorial is written after a very successful
Tenth Asian Bioethics Conference, held in Tehran,
Iran. It is testament to the aspirations of manyscholars to understand ourselves and our cultural
diversity that the Asian Bioethics Conferences andthe Four UNESCO Asia-Pacific School of Ethics
Roundtable have been held in many countries
drawing together a solid foundation of regional
scholarship.
I urge readers to submit papers to EJAIB, so that
we might be able to engage in deeper reflection of
the nature of bioethics, and lessons of realexperiences to the frameworks that will shape policy
to better outcomes. All the opinions here can bequestioned, and debated – that is the essence of
bioethics and its universal feature.
Related to these dialogues are some forthcoming
UNESCO conferences in the Asia-Pacific region,
including Asia-Arab Interregional Philosophical
Dialogues on the Crisis of Civilization, 28-30 May in
Bangkok. Experts from 30 countries will cometogether to discuss various themes, including
bioethics. I refer readers to the websites to findmore information.
-Darryl MacerEubios Journal of Asian and International Bioethics 19 (March 2009)

Institutional Review Boards,
Worldwide (IRBs)- Jayapaul Azariah, Ph.D.
Founder President, All India Bioethics Association,
New No. 4, 8th Lane, Indiranagar,
Chennai 600 020. India
Email: jazariah@yahoo.com
Abstract
The concept of Bioethics Committees evolved due to
mistreatment of human beings during the periods of war as wellas to find a medical treatment-cure for syphilis in the USA.
Bioethics committees address ethical and moral issues raised
due to the advancement of science and technology in the fieldsof Life Sciences, Biosciences and Medical Sciences. There isalso a need to develop a mechanism to address ethicallyburdened issues and provide an impetus to governments andpolicy makers for ethical governance. Such a body which
provides such logistic mechanism goes by the umbrella term of
Bioethics Committees. Bioethics Committees have taken
various dimensions such as Institutional Review Boards (IRB),
Research Ethics Committee, National Bioethics Advisory
Committee, Policy-making Bioethics Committee, Hospital and
Health Care Bioethics Committee and Medical –Healthprofessional bioethics Committees. An analysis has been madeto record the number of countries which have IRBs – out of a
total of 245 countries. A few countries have more than one
hundred IRBs and about 99 countries have no bioethicalcommittees. Special attention has been paid to Indian national
scenarios, and case studies of YRG Care and ICMR are
discussed. The need to address upcoming biotechnologicalissues in Asian countries, in the context of IRBs, has been
pointed out. The importance of recognizing medical ethics andbioethics as academic disciplines has been pointed out.
Introduction - Historical
It is well documented in eastern literature that rudiments ofmedical ethics existed from the early civilization of the Vedic
Period (3000 - 800 BC) (Azariah 2003). However, modern
medical ethics and the broader discipline of Bioethics per setake their roots from western biomedical and behaviouralsciences as well as from western philosophy. Following
historical situations provided the ground and formed thecompelling reason for the institution of Institutional Review
Boards (IRBs). The German-Nazi doctor’s inhumanexperimentation and mistreatment of prisoners during WorldWar II resulted in the emergence of Nuremberg Code in 1947.
The UN brought out the Universal Declaration on Human Rights(UDHR) in 1948.
The Tuskegee Report deals with the case of male Negro(1932-1972) in Tuskegee Alabama. About 399 and 201 healthy
human subjects, without syphilis, constituted the control group.
These human subjects formed a part of an experiment to findout a treatment-cure for the disease. The research subjects
were kept in total darkness as to the nature of the treatment
and they were not given the choice to be enrolled in the study(no informed consent). As a result the Tuskegee Syphilis Studycame to be known as the “arguably the most infamous
biomedical research study in US History”.
The Belmont Report was published in 1978 by the US
Department of Health and Human Services, explaining theunifying bioethical principles aimed at the protection of humansubjects in biomedical and behavioural research. The Belmont
Report endorses three core bioethical principles in researches
dealing with human subjects, namely respect for humanpersons / dignity, beneficence and justice. This foundational

35

statement is the driving force for the proper functioning of all
Bioethics Committees.
Provision in the Helsinki Declaration of 1964, revised in
1975, for the formation of an “Independent Committee” laid thefoundation for the functioning of the present bioethical system
of Institutional Review Boards whose primary function is tooversee the steps taken to ensure the protection of humandignity and human rights. Recognizing the fact that thediscipline of bioethics has currently undergone marked culturaland social changes the UNESCO brought out a fresh Universal
Declaration on Bioethics and Human Rights (UDBHR adopted
on 19.10.2005) which recognizes that “ethical issues inmedicine and life sciences and associated technologies may
have an impact on individuals, families, groups or communities
and humankind as a whole”. Therefore, all IRBs, in principle,
must function on the basis of bioethical principles of justice,
autonomy, beneficence and confidentiality, thus preserving thesocial stability.
Importance of Bioethics Committees
Bioethics committees concern themselves with the ethicaland moral issues raised in the advancement of science andtechnology in the fields of Life Sciences, Biosciences andMedical Sciences. It is imperative, therefore, to develop amechanism to address these issues and provide an impetus togovernments and policy makers. Such logistic mechanism goesby the umbrella term of Bioethics Committees. These
committees function in any institution where research studies
are conducted on animals as well as human subjects so as toprovide better health care. Providing improved health andenabling the sick to have the access to health care system isthe primary aim of the Bioethics Committees. In health careinstitutions it provides ethical guidance in the area of doctorpatient relationship, protecting human dignity and maintaining
confidentiality to patients living with HIV or AIDS. Depending
upon the nature and requirement Bioethics Committee hastaken various dimensions such as Research Ethics Committee,
National Bioethics Advisory Committee, Policy-making
Bioethics Committee, Hospital and Health Care Bioethics
Committee and Medical –Health professional bioethics
Committees.
Bioethics in India
The advent of 21 century has assured in an era ofbiosciences ethics. Recent developments in new biology andbiomedical sciences and their practical application in research
involving human and non-human subjects have necessitatedthe implementation of Institutional Review Boards (IRB). In an
Indian context, the discipline of bioethics was introduced for the
first time in 1996 by conducting an international bioethics
congress at the University of Madras, Chennai.
A national awareness in bioethics was created with the birthof the All India Bioethics Association (AIBA) in 1996-1997.
Bioethical maturity of a society deals with the following aspects:(i) how to control the use or misuse of newly acquired biologicaland medical knowledge and the tools of biotechnologies (ii) to
develop a critical frame of mind and (iii) to develop a system ofvalues that prepare us to judge each new biological, molecularand genetic discovery or biotechnology as it evolves as well as
to resolve problems with bioethical dilemma and (iv) it
insinuates itself into the awesome and broad domains of the life
sciences and health sciences (UNESCO, 2005 a).
Therefore, proper governance of IRBs is closely associatedwith such awareness of core principles of bioethics.
Implementation of regulatory bioethical measures through IRBs
is to ensure a competent review of all ethical aspects of theresearch project proposals involving human subjects.
Definition of IRB
A Bioethics Committee otherwise called the Ethics
Committee and the Institutional Review Board (IRB) is “a36

Eubios Journal of Asian and International Bioethics 19 (March 2009)

committee that systematically and continually addresses the
ethical dimensions of (a) the health sciences, (b) the life
sciences and (c) innovative health policies. A bioethics
committee is typically composed of a range of experts, isusually multi disciplinary and its members employ a variety of
approaches to work out toward the resolution of bioethicalissues and problems, especially moral or bioethical dilemmas.
Moreover, the members of these committees not only become
more sensitive to ethical dilemmas but also, in time, develop theknowledge and skills required to deal more effectively withthem, frequently finding ways to resolve what may at first
appear to be intractable dilemmas.” (UNESCO, 2005, a).
Bioethics committees generally have no legal authority toprosecute or take legal action against any erring institution. To
a larger extent, it protects the Principal Investigator (PI) fromany pitfalls in his research which may trigger legal proceedings
and it also ensures the protection of human dignity and humanrights of the human subjects. Just as it is protecting theinvestigator against legal proceedings it also safeguards publictrust.
World Scenario
IRB - Office for Human Research Protection
In the United States of America (USA) the Office for Human
Research Protection (OHRP) maintains a Registry of IRBs of
the world(http://www.hhs.gov/ohrp). On a national andinternational basis, it caters to the interests of human subjects
in clinical trials and provides infrastructural support in bioethics
by way of strengthening and providing leadership in the national
system for protecting volunteers in medical research. It plays arole in capacity building of IRBs in terms of assisting in solving
bioethical dilemmas, providing clarification / guidance toresearch institutions as well as academic inputs in curriculum
development in bioethics and for the education of committee
members in bioethics. It is recommended that, in every
country, similar national organization must be instituted with
their own National Registry containing the names of IRBs, ID ofwebsite information, if any, information on the area of interest
and a list of expert members.
The registry of OHRP provides information on the IRBs of
the world, from which information regarding the number of IRBs
(that they recognize) in all the countries listed in its registry wasculled out to construct the following Tables. Table 1 lists thename of countries with the total number of recognized IRBs, inan ascending order. From this source information Tables 2 and3 were constructed.
Countries with no OHRP-recognized IRBs include: Albania,
Algeria , Andorra, Anguilla, Antarctica, Antigua / Barbuda,
Aruba, Bahrain, BassasDindia, Bermuda, Bhutan, Bissau,
Bosnia / Herzegovina, Bouvet Island, British IOT, British VISS,
Brunei, Brunei Darussalam, Bulgaria, Cape Verde, Cayman
Island, Central African Republic, Christmas Island, Clipperton
Island, Cocos Keelng Islands, Comoros, Cook Islands, Cyprus,
Djibouti, Dominica, Equator Guinea, Europa Island, Falkland
Islands, French Guiana, French So/Antarctic lands, Gaza Strip,
Gibraltar, Glorioso Islands, Greenland, Grenada, Guadeloupe,
Guernsey, Guinea Bissau, Guyana, Heard/Mcdonald Islands,
Iraq, Jan Mayen, Jersey, Juan de Nova Island, Kiribati, Kuwait,
Libya, Liechtenstein, Macau, Marshall Islands, Martinique,
Mauritania, Mayotte, Micronesia, Montserrat, Namibia, Nauru,
Netherlands Antilles, New Caledonia, New Guinea, Niger, Niue,
Norfolk Island, Oman, Paracel Iss, Pitcairn Islands, Qatar,
Reunion,Saint
Helena,Saint
Kitts/Nevis,
Saint
Vincent/Grenadines,
San Marino, Sao Thom/Principe,
Solomon Islands, Somalia, Spratley Islands, Suriname,
Svalbard, Swaziland, Togo, Tokelau, Tonga, Tromelin Island,
Turkmenistan, Turks/Canicos Island, Tuvalu, Unknown,
Vanuatu, Vatican City, Wallis/Futuna, West Bank, Western
Sahara, Yugoslavia, Zaire
Countries with one OHRP-recognized IRB include:
Afghanistan, Angola, Azerbaijan, Bahamas, Barbados, Belize,
Benin, Botswana, Burma- Mayanmar, Burundi, Chad, Cuba,

Faroe Islands, Fiji, French Polynesia, Gambia , Guinea,
Iceland, Korea Peoples Republic, Laos, Lesotho, Liberia,
Luxembourg, Maldives, Mauritius, Monaco, Mongolia,
Mozambique, Palau, Panama, Rwanda, Saint Pierre/Miquelon,
Seychelles, Sierra Leone, Sudan, Syria, Tajikistan, United ArabEmirates, Uzbekistan, Yeman,
Countries with two OHRP-recognized IRBs include:
Madagascar, Congo, Gabon, Honduras, Ivory Coast, Jordan,
Kosova, Kyrgyzstan, Lebanon, Macedonia, Mali, Papua New
Guinea, Paraguay, Senegal, Slovenia, Tunisia,
Country list of IRBs
It can be inferred from Table 3 that the concept of IRB has
not taken roots in almost half the countries of the world. The
number of IRBs present in a country may be governed by the
degree of advancement in Science and Technology, its per
capita income as well as by its land area. For instance, Italy(100) and Australia (106) are countries with less land mass
when compared to Canada (175) and Mainland China (159).
But they are relatively, thickly populated with IRBs. A criticalanalysis of the Tables may indicate that more education in
Bioethics and in house training in establishing IRBs and its
functional features are to be introduced in all these countries
where Bioethics Committees have not taken roots or not
functioning to solve ethically charged issues – Ethical, Legal,
Social Issues (ELSI).
Table 3: Number of countries and the Number of OHRPrecognized IRBs
N. IRBSN. Countries
Zero
99
One
40
Two
16
Three
13
Four
07
Five
06
Six
06
Seven
02
Eight
05
Nine
08
Ten
04
11-20
16
21-30
08
31-40
05
41-50
03
51- 9905
100 & Above 06
HundredCountries with 100 or more IRBs
Table 2 provides data on the number of countries whichhave one hundred and more IRBs. There are only six countries
which fall under this category. It may be noted that India is one
among them having a total 137 IRBs. Canada tops the list,
followed by Mainland China and United Kingdom,
Table 2: Number of Countries with 100 or more IRBs
Nr.
Country
IRBs
1
Canada175
2
China Mainland
159
3
United Kingdom
153
4
India
137
5
Australia
106
6
Italy
100
A complete country wise listing was prepared (Table 2). Outof 245 listed countries almost 99 countries do not have a single
functioning IRB. About 40 countries have only one IRB. In
about 13 countries there are just 3 IRBs. About 16 countries
have a few IRBs, i.e. between 11 and 20 (See Tables 1 and 3
for details)

Eubios Journal of Asian and International Bioethics 19 (March 2009)

Table 1 Country wise Distribution of ORHP-recognised IRBs:
Total Number of countries = 245 (countries with 0,1 or 2 IRBs
are listed in text) Source link http://www.hhs.gov/ohrp/

Nr.
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204

Country
Burkina
El Salvador
Haiti
LatviaLithuania
Malawi
Moldova
Nepal
Nicaragua
Saudi Arabia
Sri Lanka
ZambiaZimbabwe
Austria
Bangladesh
Croatia
Estonia
Serbia /Montenegro
Trinidad/Tobago
Venezuela
Cambodia
Ethiopia
Iran
Kazakhstan
MoroccoSlovak Republic
Cameroon
Ghana
GreeceJamaica
NorwayUruguay
Belarus (7)Kenya
Armenia
Bolivia
Costa Rica
Dominican Republic
Malaysia
Bulgaria
GuatemalaRomania
EcuadorIndonesia
Tanzamia U Republic
UgandaPhilippines
TurkeyNr. Of
IRBs
3
3
3
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
5
5
5
5
5
5
6
6
6
6
6
6
7
7
8
8
8
8
8
9
9
9
10
10
10
10
11
12

A detailed list is provided in Table 1 for countries with morethan 2 recognised IRBs. Most countries, which do not have an
IRB are the underdeveloped or developing countries. In suchcountries e.g. Albania, other human rights related problems
such as human trafficking of young girls may have to beaddressed along side with the establishment of regulatory
measures like IRBs. It is likely that a new strategy may have to
be followed which will build these countries economically,
upgrade their present state of art in of Science and Technology
and simultaneously helping them to establish IRBs.

Nr.
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245

Country
Denmark
Pakistan
Portugal
Singapore
Georgia
Ireland
Egypt
Switzerland
Czech RepublicNetherlands
New ZealandTaiwanVietnam
Chile
FinlandIsraelFranceUkrainePeru
Colombia
South Africa
SwedenBelgium
Hungary
ThailandNigeria
PolandGermany
MexicoArgentina
Spain
Japan
Korea Republic of
BrazilRussiaItaly
Australia
India
United Kingdom
China Mainland
Canada37

Nr. Of
IRBs
13
13
13
13
14
14
15
15
16
16
17
17
17
20
21
25
26
26
27
28
28
28
32
33
34
38
40
45
45
46
52
54
55
90
92
100
106
137
153
159
175

In this context, it may be mentioned that a National
Conference “On Alternative IRB Models: Optimizing Human
Subjects Protection” was conducted during November 20-21,
2006 at Washington DC, USA. This conference sought to solve
emerging future sophisticated bioethical problems. It will behighly contextual if an alternative model to the existing
American model of IRB is developed to build these countries
from the scratch, both economically and bioethically.
As pointed out earlier, UNESCO advocates the formation ofdifferent types of committees to suit different needs andrequirements in formulating the ethical guidelines dealing withresearch on human subjects such as 1. Policy making andAdvisory Bioethics Committee 2. Health professional
Associations’ Bioethics Committee, 3. Health care and HospitalCommittee and 4. Research Ethics Committee. But in reality,
most hospitals and medical institutions have mostly a single
type of IRB to oversee diverse aspects of research projects.

38

Eubios Journal of Asian and International Bioethics 19 (March 2009)

Indian National Scenario: IRB distribution in India
There are about 137 IRBs spread across the nation of India(Table 4). There are 28 States and 7 Union Territories in India.
Out of these, only 14 States and 2 Union Territories have IRB.
Maharashtra tops the list with 28 IRBs, followed by Tamil Nadu
(20), Karnataka (18), Union Territory National Capital Delhi (18)and Andhra Pradesh (10). States like West Bengal, with a big
city like Kolkata (Calcutta) has only 6 IRBs (Table 6).
A city wise breakup of figures is given in Table 5. Mumbai
stands highest with 19 IRBs followed by New Delhi (18),Bangalore (12), Chennai (12) and Kolkata (06). It is interesting
to note that in an ancient and thickly populated city like Kolkata(Calcutta) there are only 6 IRBs. In major cities like Trivandrum,
Pune, Jaipur, Mysore, Ahmedabad, Kochi and Goa, the numberof IRBs is between five and one. Although there are about 12
IRBs in Chennai, the total number of IRBs for Tamil Nadu State
amounts to about 20. Only two cities, Kochi and Trivandrum, inthe state of Kerala, have a total of 7 IRBs. In Orissa State there
are only five IRBs, all of which are located at the capital city of
Bhubaneswar.
Following areas have been mentioned as areas for which
IRBs
exist,
namelybiomedical,
hospital
ethics,scientific/biomedical, bio-psycho-social, biological, bioethicaland epidemiological. Most of the Institutions have notmentioned their area of specialization. Such information should
be included in the National Registry of IRBs, which is yet to becreated.
Table 5: Number of IRBs in different Indian Cities
Location
Total IRBs
CitiesState
Mumbai(Maharashtra)
New Delhi,(Union Territory)
Bangalore(Karnataka)
Chennai(Tamil Nadu)
Kolkata(West Bengal)
Trivandrum(Kerala)Pune(Maharashtra)
Bhubaneswar (Orissa)
Jaipur(Rajasthan)Mysore(Karnataka)
Ahmedabad(Maharashtra)
Kochi(Kerala)
Goa
(Goa)

19
18
12
12
06
05
04
04
03
03
03
02
01

Table 6: Number of IRBs in Indian States
Nr.

Indian States

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Maharashtra
Tamil Nadu
Karnataka
New Delhi (UT)
Andhra Pradesh
KeralaUttar PradeshWest Bengal
OrissaPunjabGujaratRajasthan
Madhya Pradesh
Goa
Mizoram
Chandigarh (UT)UT = Union Territory

Nr of
IRBs
28
20
18
18
10
07
06
06
05
05
04
04
03
01
01
01

Regional Scenario: YRG CARE - A Case Study
Incidence of AIDS was recorded at Chennai during 1980s by
Dr. Sunithi Solomon and her team of research workers. She
heads a non governmental organization (NGO) ‘The YRG

CARE’. This Centre for AIDS Research and Education (CARE)
is part of YR Gaitonde (YRG) Medical, Educational andResearch Foundation, (YRG CARE). YRG Care as a NGO,
works among people living with HIV and AIDS. The IRB ofYRG Care, was instituted in 1998 and functions on a local level.
i.e. at Chennai and it inducted the President of All India
Bioethics Association as one of the IRB members at its very
inception.
Its Institutional Review Board (IRB) is a registered body ofexperts (January 1999). In accordance with the Internationaland National (The Indian Council of Medical Research - ICMR)
guidelines on research protocols for conducting research on
human subjects, it has a Federal Wide Assurance (FWA)(March 2001) with the Office for Human Research Protections(OHRP)..The tenure of the FWA is renewed after a three-year
period.
Composition of Experts
Experts who are IRB members are drawn from diverse fields.
They include scientific researchers in biological, social sciences
and medical fields. With the primary aim of enforcing protectionof the rights and welfare of the human subjects, the IRB has
microbiologists, legal advisor, development consultant, social
scientists, ophthalmologists, HIV /AIDS activists for women,
psychiatrists, economists, bioethicists and general medicine. At
one stage there were members who were living with HIV(PLHIV). Its IRB members are dedicated to the health of PLHIV
and especially to ensure their easy access to health care. The
Board members are required to undergo a course of
training/workshop and pass an online test on the prescribedbackground resource materials. Such academic climate equips
IRB members to identify the unethical use, if any, of new
developments in biological and medical sciences. The IRB
meets usually once in a month, on a Saturday agreed by themembers in the previous meeting. The regularity of the meetingis governed by the arrival of new research proposals for review,
as well as on going projects. Although the IRB members serveon an honorary/voluntary basis provision has now been madeto cover their conveyance expenses to attend the board
meetings.
Fixing IRB meetings is meticulously managed by the
Coordinator who is specially appointed for this purpose. All
Principal Investigators (PIs) are required to submit their
proposals well in advance to the IRB Coordinator who finalizes
the agenda and distributes the study material to all the IRB
members well in advance. One of the difficulties in having
continued interest of the IRB members in attending review
meetings is that of time. Everybody is too busy during theworking days and/or on Saturdays they may be out of city. Yet
they find time for this important job. The Coordinator telephones
each member, a few days before, and confirms their availability
since all are busy. Very rarely a meeting is cancelled due tolack of quorum. Usually meetings are postponed for another
Saturday when the members are free and available. All
meetings are chaired by the Chairman who is elected by thecommittee members.
Review Procedure
All PIs, including foreign researchers, are required to present
their proposals within the allotted time slot, usually done withpower point slides. The IRB scrutinizes the proposal without
any fear or favour. Suggestions are made for any improvementwith respect to methodology, sample size, and the correctnessof the questionnaire to be administered in studies that involve a
survey. All PIs of such projects are required to state theobjection that was pointed out in the earlier review along withthe remedial steps taken to concur with the earlier remarks. Allrevised proposals are finally submitted for approval. No
research project is approved without the collective decision of
the IRB members. The IRB coordinator electronically records
the proceedings and distributes the minutes of the meeting one
week prior to the meeting and maintains all files andEubios Journal of Asian and International Bioethics 19 (March 2009)
correspondence. All IRB approved projects are submitted to theCentral Ethics Committee of ICMR for its review and approval.
Effective functioning of the IRB has ensured that “allresearch conducted by YRG CARE is in compliance with thehighest ethical standards”. For fulfilling the primary purpose of
the IRB which is to ensure the protection of the rights andwelfare of human subjects in research at YRG CARE each
proposal is reviewed as to its content and protocols such as theinclusion and exclusion criteria, informed consents and reports.
The IRB mainly concerns itself with the research proposals
of YRG Care. The IRB is fully apprised of the plan of research,
the aim of research and its impact and possible risks andensures the principles of informed consent and voluntary
participation, privacy and confidentiality. It also takes into
consideration the existence of regional and cultural variations inIndia. It safeguards the rights and welfare of the humansubjects who will serve as the candidates for the research work.
Due to the tendency of stigmatisation of HIV/AIDS candidates,
extreme care is taken to keep the case history of eachcandidate as confidential reports. Secondly, researchers who
use the case sheet of patients (medical records) for obtaining
data for publication purposes are extremely careful to keepsuch data confidentially and maintain the anonymity of thepatients. Similarly blood samples of infected patients would not
be allowed to be subjected to another research proposal, if
there is no clear statement permitting blood samples obtained
under one research proposal to be used in another new
research proposal. Such multiple uses of blood samples shouldhave been clearly stated in the informed consent form. If not, no
permission is granted to swap blood samples.
Informed consent – A Living Document
In accordance with The Belmont Report and the Indian(ICMR) Ethical Principles and Guidelines for the protection of
Human Subjects, greatest emphasis is given to informed
consent. Informed consent is a difficult preposition in an Indian
context. Illiteracy is one such problem. Secondly, the role offamily members and of the Head of a village community can not
be underestimated! Rarely the patient is involved in signing an‘informed consent form’. Generally it is the family that takes the
final decision.
YRG CARE caters to the medical needs of people with
HIV/AIDS within a multilingual community – the Tamils, The
Telugus and the English speaking South Indians. Hence, all theinformed consent documents in English language are translated
into regional languages, Tamil and Telugu languages. Eachtranslation is back translated into English to verify the accuracyof translation by a third person. Translation is redone if there
are wide deviations from the meaning of the original English
document. Therefore IRB considers the process of obtaining
informed consent as of crucial importance. Hence, it considers
the signed informed consent form not as some mere piece of
paper but as a living document which to be preserved andreferred to till the end of the research program. IRB of YRG
CARE does not permit oral informed consent. Therefore,
meticulous care is taken to enforce the principle of informed
consent either by electronic means or by oral explanation, if thepatient is illiterate. In the latter case, thumb impressions arecounter signed by a witness.
Protocol Deviations
Entrusted with the responsibility of not only the initial reviewof the research-proposal- protocols, prior to the initiation of the
projects but it also has a continuing responsibility of regularmonitoring for the compliance of the ethics of the approved
program still the completion of the project. Further, if there areany deviations from the reviewed protocol procedures that were
earlier approved by the IRB then the PI of the project isrequired to present his/her proposal again with reasons for thedeviation. IRB reviews the proposal again and then approves.
As part of continuing review, all the PIs are required to update39

the IRB members of the progress made in their research projectfrom time to time.
Finally, every PI presents a completion-presentation of theirproject. Such reports are published in reputed journals and a
copy of the reprint of the research paper is posted to all IRB
members. Such activities are part of the continuing education of
the IRB members. Since, not all IRB members are well versedwith the terminology used in AIDS research such repetition
helps
the
educationofthemembers.
Community Development
YRG CARE has two ethics committees. The Community
Advisory Board (CAB) provides the needed impetus to design
research projects ethically, especially those under the HIV
Prevention Trials Unit (HPTU), as well as to enhance benefits
for and participation of the community. The IRB members andcommunity workers meet together over a meal to get to know
the field work.
ICMR – Central Ethics Committee
All IRB approved projects are submitted to ICMR’s Central
Ethics Committee (CEC) for its review and approval. The
seventeen members of the CEC of the ICMR are experts in thefields of medical sciences, pharmacology, law, social science,as well as heads of different religious groups and others.
Inclusion of representatives of different religious groups as well
as philosophers has always been a problem due to the fact ofdifferent ideological stand taken by different groups on acommon bioethical problem. The members meet to review andto sanction clearances to proposals referred by the Departmentof Biotechnology, the mother-to-child transmission studies
referred by National AIDS Control Organization (NACO) and
Ministry of Health and the preventive AIDS Vaccine trials being
conducted jointly by ICMR, NACO and International AIDS
Vaccine Initiative (IAVI). It has also the responsibility ofproviding clearances to all the proposals referred by the 137
local IRBs. Such a load of work on CEC there is always
enormous delay in obtaining ICMR’s clearance. As a result,research projects that are funded by foreign funding agencies
suffer loss of financial support. Due to such inordinate delays in
obtaining the final sanction, there is also the possibility to swap
(plagiarism) a research project submitted by one IRB byanother.
The Unethical Side
Instances of plagiarism have been reported from time totime.
The Society of Scientific Values (SSV) serves as awatchdog to spot any unethical practices in science andtechnology. Recently SSV has brought to light two instances ofplagiarism and data swapping. In one instance is related to a“prominent government report” and the other is a research
publication of a nationally reputed National Centre for Cell
Sciences. (NCCS) (Padma, 2007). The “horns of bioethicaldilemma” is that two different committees - The Institutional
Enquiry Committee at NCCS and an Independent Committee came to contradictory conclusions and recommendations. On
this very issue of conflict of interest, the SSV demands
immediate creation of “an independent ethics body with
sufficient legal powers to enforce integrity in Indian Science”
In the United States of America, besides regular IRBs
attached to a recognized institution, there are many othercommercial IRBs which work mainly as profit making
organizations. Such commercial IRBs have been under the
scrutiny of Food and Drug Administration (FDA) of USA. And
yet “no governmental agency has systematic data oncommercial IRBs” (C-IRBs) (Lemmens and Freedman, 2000).
The root cause for the emergence of C- IRBs is the insistence
by federal funding agencies and the FDA for the approval by an
IRB to qualify a PI or an institution to secure funding. Therefore,
the following recommendations have been made. “Within the

40

Eubios Journal of Asian and International Bioethics 19 (March 2009)

regulatory setting, procedural conflict-of-interest rules are
essential because of the absence of clear substantive rules in
research review and the reliance on the fairness and good
judgment of Institutional Review Board members. Current
guidelines and regulations lack adequate conflict-of-interest
rules and provide insufficient details on the substantive rules…
However, conflict of interest rules are essential to safeguard
public trust.” (Lemmens and Freedman, 2000).
In an Indian context, it may be recalled that at one stage, the
UGC introduced the guideline that it was necessary for an
academic to qualify for the Ph.D. degree. Then many
commercial ‘Thesis writing shops” sprung up. In order toprevent the reoccurrence of such a phenomena it must be
made mandatory for all Indian IRBs to be registered with aCentral Government Agency in India which will have systematic
data on infrastructural details of a given IRB.
The Divide between Developed and Undeveloped Countries
When bioethics was introduced into India mindset during
1996, it was widely commented that it is a luxury for India. Aftera decade of activities, it is now felt that it is a necessity forsocial stability. Similarly, Coleman and Bouesseau (2006) argue
that “ the structure of the American IRB system is poor fit for
African countries”. However, fifteen African countries havejointly formed a networking called the Networking for Ethics on
Biomedical Research in Africa” (NEERA) to survey theparticipating countries’ existing systems for ethics review of
research involving human participants and develop a strategy
for strengthening it” (Coleman and Bouesseau, 2006). Twoissues are involved. Will the American regulatory system of IRB
work in the countries listed in Table 1 which do not have asingle IRB? Secondly, existence of some such regulatory
system is better than having none! However, there is a need toadopt the American system of IRB with suitable modifications tosuit local conditions.
International Collaboration
The ICMR has provided “Guidance for International
Collaboration for Research in Biomedical Sciences” which isregulated by the International Health Division (IHD). Research
projects in the major area of Science and Technology have an
implication in biomedical research and Human Health. Hence,both the Government of India and the ICMR have signed
specific bilateral agreement with other countries. Such ageneral agreement includes areas such as exchange ofscientific personals and information, joint execution of scientificprojects, procurement of infrastructural equipment and fororganizing conferences and seminars. However, applications
for carrying out research projects in India with foreign funding inbiomedical / health research are to be submitted to ICMR (IHD).
All such research proposals have to be approved by theGovernment of India, Ministry of Health’s Screening Committee(HMSC).
It may be noted that the procedures /instructions and theapplication format vary from country to country. For instance, in
any INDO- US collaboration, applications have to be submitted
to NIH Grants for their approval as well as the approval of therespective IRB. The NIH application format may be downloadedfromthewebsite http://grants2.nih.gov/grants/funding/phs398/phs39
8.html . All NIH approved research proposals are submitted to
the Indian counterpart agencies for the approval of theirrespective IRBs. In the case of research proposals involving
human subjects with HIV/AIDS all proposals that are approvedby their respective IRBs need the approval of ICMR’s Central
Ethics Committee and by the Ministry of Health’s screening
Committee (HMSC) whose secretariat is in the office of ICMR
as well by the National AIDS Control Organization.
In this context it may be pointed out that the National
Bioethics Advisory Commission of UK considered ‘there arelegitimate reasons to question the capacity of host countries tosupport and conduct prior ethics review’ of collaborative

research. Nuffield Council on Bioethics is of the opinion“strengthening the ethics review capacity of low and middleincome countries is therefore, an important goal of international
bioethics and human rights (Coleman and Bouesseau, 2006).
Influence of Philosophers in the Committee
It has been pointed out earlier that Indian IRBs, unlike theAmerican/European counterparts, may not have a philosopher
on its board (Azariah, 2005). The influence of having aphilosopher on the Board and in other advisory or legislative
body or not having one, can be illustrated by two historic
instances.
The U.S. House of representatives recognized that a federal
crime against a pregnant women claims two victims, passing
the Unborn Victims of Violence Act (H.R. 1997), also known as"Laci and Conner's Law," by a vote of 254-163. The bill would
recognize as a legal victim any "child in utero" who is injured or
killedduringthecommissionofa(http://www.lifesite.net/ldn/2004/feb/04022603.html)
federalcrime of violence. Two areas need to be addressed. (1) it isgood that it recognizes the rights of a “child in utero”. 2) The
usage of the world child indicates that the unborn fetus is aperson. It remains to be seen how such an implication will betaken by an American philosopher, who may not generally
recognize a foetus as a person.
The Great Divide
It is interesting to note that, in the Western Civilization, it israre to find any bioethics committee without a philosopher. In
fact most of the bioethical dictums are influenced byphilosophical undercurrent. Socio biologists thought that such adomination is not always good and hence "Scientists andhumanists should consider together the possibility that the time
has come for ethics to be removed temporarily from the handsof the philosophers and bioligicized" (Wilson, 1975). On thecontrary, it is interesting to note that in the Indian context,
bioethics was introduced to the Indian intelligentsia by
biologists. Hence many natural scientists have become expertbioethicists. Indian philosophers are immersed in the varied
shades of Indian philosophy and hence it is very rarely aphilosopher is interested in Ethical Legal and Social Issues(ELSI). Biologists can speak philosophy but it is hard for an
Indian philosopher to speak bioethics based on biologicalconcepts since they have no exposure to biology in theircollegiate education.
The Unbridgeable Divide
As a result, it has been pointed out in an earlier paper that
the Ethical Committee which formulated the Indian Ethical
Guideline of Human Subjects in Biomedical Research of 2000
didn’t have philosophers on its Board. In consonance with theIndian belief system (cultural/scriptural) it made a statementthat the fetus is a person (Azariah, 2005). In this context, therecent judgment of an Indian judge is interesting. An Indianstate consumer court (MUMBAI, India, March 7, 2007) has
delivered an unprecedented ruling in favour of a woman
seeking an insurance claim on the death of an unborn child--thecourt determined that the unborn baby was a living humanbeing entitled to personhood and required the insurancecompany to pay the claim (Personal email communication with
Prof Bing Tang, NY, USA).
Difficulties in implementation
Guidelines advocated by the ICMR have no legal bindingson any research institutions and hospitals in India. As there is
no provision for compulsory enforcement of ICMR ethicalguidelines, they are to be adhered to by voluntary compliance.
Although these guidelines have been released by a nationalorganization like the ICMR it has no regal authority to take any
action against those who violate the rules.
Therefore, one of the greatest difficulties is that of
implementation and monitoring. The following question wasEubios Journal of Asian and International Bioethics 19 (March 2009)
asked to Dr. Vasantha Muthuswamy of ICMR “Is there amonitoring mechanism to ensure ethical processes such as
informed consent, recruitment and compensation are carriedout during the clinical trials? She replied “There is no propermechanism in position at present. It is recommended that
Institutional Ethics Committee take up the monitoring role bysite visits to ensure compliance. It will take some more time tomake these things really happen” (IAVI 2007). Even though
there is a law preventing the misuse of organ transplants,
especially with reference to kidney transplants, enforcing thelaw is far too difficult.
If the task of monitoring the enforcement of ICMR guidelines
is left with local IRBs it is far more difficult. Recently, about
thirteen hospitals were deprived of their licenses to perform
kidney transplants due severe malpractice in kidney trade(Kannan, 2007 a, b., Azariah, 2007). Following are the namesof hospitals, in the state of Tamil Nadu, involved in kidneyracket:1.Vedanayagam Hospital (Coimbatore), 2
PSG
Hospital, (Coimbatore) 3. Kovai Medical Centre, (Coimbatore),
4.G. Kupuswamy Naidu Hospital, (Coimbatore) 5.
KaveryMeidcal Centre, (Trichy), 6. Ramakrishna Nursing Home,(Erode) 7. Galaxy Hospital, (Tirunelveli). 8 Devaki Hospital,(Chennia), 9. Chennai Transplant Centre, Madras Medical
Mission, (Chennai), 10. ABC Hospitals, (Chennai), 11.Chennai
Kaliappa Hospital, (Chennai), 12. Apollo Speciality Hospital,(Madurai) and 13. Meenakshi Medical Mission, (Madurai).
Apparently, in all these hospitals of refute there is no IRB or
Hospital Ethics Committee!
Enormous Delay in Future Hopes
Although the ICMR guidelines for biomedical research on
human subjects were circulated as a consultation paper as
early in 1997 it was finalized only in 2000. However, it was only
recently it has been given the shape of a Bill. As on date, theBill awaits that it is passed as a Law by the Indian Parliament(IAVI, 2007). Almost it has taken seven years to reach thisstage, during which the ground realities and cultural and social
norms change drastically. ICMR hopes that once the Bill
becomes a law then it becomes “mandatory for all clinicalstudies, conducted by both physicians and non-physicians, tofollow the guidelines. Currently, there are laws governing
research in India. Under the Drugs and Cosmetics Act all trials
in the country should follow the ICMR guidelines. Medical
Council of India Act amended in 2002 states that all research inIndia carried out by physicians has to subscribe to the ICMR
guidelines. This is an indirect legal support to enforce ourguidelines but we need more teeth!” ICMR also hopes that all
researchers in biomedical sciences may undergo a course of
training in ethics before taking up a research work. The
proposal that all postgraduate theses should go through IRB
clearance may not be a reality due to time factor.
Ethics Committees and the Future
There is a need to establish ethical guidelines in animal
rights where animals are employed in toxicological research.
Technological universities and pharmaceutical companies
connected with drug and cosmetic research invariably animals
are used. There is on appropriate Scientific Ethical Review
Committees which looks into this matter.
Development of human resource to solve our common futurebioethical issues and concerns, in newer areas ofbiotechnological research in genetic engineering, IVF, humanembryonic stem cells (hESC) research and human egg
donation are areas of exploration and exploitation. Hence,these sophisticated newer fields definitely need safeguards andlaws to confer human rights to vulnerable humans. Currently,
The Indian Council of Medical Research (ICMR) located at New
Delhi takes the responsibility of approving all research projects
involving human subjects nationwide and to enforce theprinciple of non violence in biomedical research by assessing

41

the risks and benefits of these new advancements in scienceand technology.
One Central Bioethics Committee may not be effective togovern newer areas of research involving human subjects.
Afore mentioned national (USA) conference “On Alternative IRB
Models: Optimizing Human Subjects Protection” foresaw such aproblem. The two main objectives of the conference were thefollowing: (i) To optimize and facilitate institutional access toappropriate ethical and scientific expertise for reviewing
increasingly sophisticated projects and (ii) To optimize
institutional resources to review such projects.
It is recommended to create a National Bioethics Authority or
National Bioethics Commission so as to bring regulatory
measures in research involving human subjects as well as nonhuman subjects. More importantly, regulatory mechanisms,
which restrict scientific research in grey areas, are to beconsidered. These are two aspects which need current
attention.
Educating the IRB
Successful Bioethics Committees usually begin the process
of education slowly, introducing the process of self-education
when they first begin to convene as a group. Bioethics iscomplex and multifaceted discipline, drawing on philosophy andlaw as well as science and medicine. Most committee members
will lack special training and experience in bioethics, andthough they typically have significant expertise in other fields,
will be willing to devote some time to this multi-disciplinary field.
In the world of Bioethics Committees the horns of bioethicaldilemma are ever changing. With the advancement of newscientific discoveries and new biotechnologies, governments allover the globe are introducing new bioethics-related-policies
and regulations with new judicial rulings. With the changing
culture new worldviews evolve in a society. Professional
attitudes to these new ethical legal and social issues change
dramatically. Hence, committee members are to be equippedwith bioethical infrastructural cementing factors which will
enable them to address the new forms of horns of bioethicaldilemmas effectively. Since the issues are multidimensional innature IRB members need to undergo intensive education.
UNESCO advocated self education and long-term intensive
education in fields like biology, biosciences, biotechnology,
medicine and law. It remains to be seen how effective will be
the process of intensive self- education in an Indian context!
It may be recalled that bioethics was introduced in India as
early as 1996 through the creation of All India Bioethics
Association (AIBA) in Chennai. And yet it has not taken roots
into Indian academic curricula. As far as the Tamil Nadu
medical curriculum is concerned there the subject of Medical
Ethics has not yet been introduced (MCI, 2008). Currently
bioethics has not been recognized as an academic discipline inmedical schools in Tamil Nadu, of which Chennai is the capital.
Hence universities have no Departments of Bioethics. And‘Medical Ethics’ has not been taught as a major subject in the
medical curriculum. Consequently students are not expected toundergo any university terminal examination to obtain theirDegree Certificates in Medicine. If Indian IRBs are to havequalified members on its Ethical Review Committees then it ismandatory that medical students and students of other related
subjects as well as IRB members should be well educated in
the many areas of bioethics so as to be qualified to serve as
members of IRBs. Creating human resource in bioethics is aprerequisite for the good and bioethical governance of research
involving human subjects through IRBs.
Education inintervention bioethics is an area for immediate concern of
crucial importance, if Indian IRBs is to function oninternationally accepted norms (Azariah, 2006). It is therecommendation of the UNESCO (2005, a, b) that every
country has its own IRBs both at the National and Regional
levels. However, in comparison with the extent of the land of

42

Eubios Journal of Asian and International Bioethics 19 (March 2009)

India and number of health-care institutions, there are just a few
local IRBs catering to the ethical needs of a given area.
Acknowledgements
My thanks are due to Mr. John Eugene Jesudason, Coventry
University for providing logistic support and internet facilities fora period of four moths which enabled me to launch andcomplete this paper.
References
Azariah, J., 2003 The Long History of India Medical System
and Current Perspectives in Health Care Bioethics. IN The
Annals of Bioethics. Regional Perspectives in Bioethics. Eds.
Peppin, J.F. and M.J. Cherry. Swets & Zeitlinger Publishers.
USSE The Netherlands. 285-300 (PP 1-380)
Azariah, J.,2005 Some bioethical Issues in Indian
Ethical Guidelines in Biomedical Research on Human
Subjects. International Joint Bioethics Congress: Inter-Cultural
Bioethics: Asia and the West. Asian Bioethics Association andTurkish Bioethics Association Sanilurfa, Turkey. 14-18, Nov,
2005. Abstract Page No.105 106 & Turkiy Klinikleri Journal of
Medical Ethics, Law and History. 13: 165–173.
J. Azariah 2006 Bioethics Education as an Intervention
Bioethics. UNESCO International Conference on Bioethics
Education. July 26-28, Seoul Korea.(In Press).
Azariah, J., 2007 Future: Sustainable Bioethics of policy andgovernance amidst ethical dilemmas in organ transplantation
through human enhancement. Society for Medical Ethics andLaw. Proceedings of the International Congress on Medical
Ethics and Medical Law. Antalya, Turkey. October 17-20,
2007. (In Press)
Coleman, C.H and Bouesseau, M.C., 2006 Strengthening
Local Review of Research in Africa: Is the IRB Model
Relevant? Bioethics Forum. Friday December 22, 2006 1-4.
IAVI 2007
In Conversation: Dr. Vasantha Muthuswamy.
International AIDS Vaccine Initiative India
Newsletter ,Sankalp 6: 2 April-May 2007. p. 6 www.iavi.org.in
Kannan, Ramya, 2007 a Transplantation licenses withdrawn:
Two Chennai hospitals found quietly of forging organtransplantation orders. The Hindu 13.04.07 p. 1
Kannan, Ramya, 2007 b Organ
Donation
authorization
Panel’s Decision likely to go online. The Hindu 19.06.07 p. 5
Lemmens, T and Freedman, B., 2000
Ethics Review for
Sale? Conflict of Interest and Commercial Research Review
Boards. The Milbank Quarterly 78: (4 ) 547-584
MCI 2008 Medical Ethics in the MBBS Curriculum soon. The
Hindu 05.07.08 p. 14
Padma, T.V., 2007
India “needs Independent Ethics
thBody” Says Watchdog. SciDevNet 27 February 2007. pp 1-2.
UNESCO 2005a Establishing Bioethics Committees: Guide No.
1. UNESCO, The Division of Ethics of Science andTechnology, Paris. Pp 71.
UNESCO 2005 b Establishing Bioethics Committees: Guide No.
2. UNESCO, The Division of Ethics of Science andTechnology. Paris. Pp 72
UNESCO 2007 Educating Bioethics Committees. Guide No.
3. UNESCO, The Division of Ethics of Science andTechnology. Paris Pp 80.
Wilson, O. E. 1975 Sociobiology: The New Synthesis. Belknap
Press of Harvard University Press, l975, pp 562.

Contextualizing Bioethics:
The UNESCO Declaration on
Bioethics and Human Rights
and observations about
Filipino Bioethics- Lukas Kaelin, PhD
Institute for Ethics and Law in Medicine
University of Vienna, Austria
Email: lukas.kaelin@univie.ac.at
Abstract
This paper examines the question of the universality ofbioethical norms by contrasting the UNESCO Declaration on
Bioethics and Human Rights (UDBHR) with aspects of Filipino
bioethics. Starting with an exploration of the vagueness of theconcept and scope of bioethics, this paper will in turn discuss
the UDBHR and distinguish it from key notions in Filipino
bioethics. The outlook of Filipino bioethics that I have observed
differs significantly from the UDBHR emphasis on the principles
autonomy and justice. This discrepancy leads to somereflections on the culturality of bioethics and on the nature ofbioethics in the Philippines. Filipino bioethics as a test caseshows the embeddedness of bioethical questions in the culturalcontext as well as the Western biased scope and content of the
UDBHR. This conclusion, however, does not rule out auniversalistic approach to bioethics, but it asks to reconsider
the culturally biased outlook of its presumably universalistic
principles.
1. Introduction
The January 2009 issue of EJAIB focused on the ultimately
philosophical question about the nature of bioethics. This paper
will attempt to provide a contribution to this topic connecting aswell the issue raised by Karori Mbữgua about the existence of agenuinely African bioethics as well as the relation between
normative and descriptive bioethics discussed by Jon Vegar
Hugaas in the same volume. However, this paper will focus on
the Asian context (specifically the Filipino context) in relation to
the hegemonic Western bioethics discourse. This paper
attempts to provide a contribution to the ongoing discussion
about whether there can be a normative global bioethics
without falling into a form of moral imperialism. Filipino bioethics
is used as a test case in contrast with the UDBHR in order toexamine the extent of the universality of bioethical norms.
The UDBHR (2005) explicitly argues in favor of a global
bioethics, thus – after an introduction into the problematic term
“bioethics” (2) – I will provide a short recapitulation of thisdeclaration. I will argue that the UDBHR attempts to bind
together the different understandings of bioethics, but that itremains Western in its main orientation (3). The problematic ofsuch an understanding of bioethics is explored in the next
paragraph, which deals with the problems of implementing sucha notion of bioethics in the cultural context of the Philippines(4). This brings me to a more general point, namely the roots ofscience as such as well as specific scientific disciplines in asocial, cultural and historical context (5). A last paragraph willoffer some general remarks about bioethics in the Philippines(6).
2. What is Bioethics? A tentative approach
The literal understanding of bioethics does not provide much
guidance in grasping the concept of bioethics: Life-ethics. Allforms of ethics are dealing with life in one way or another: If we
ask for example with Aristotle what the good life is, or if we ask
with John Stuart Mill how we can maximize utility, or if we apply
Immanuel Kant’s Categorical Imperative, we always deal with

Eubios Journal of Asian and International Bioethics 19 (March 2009)human (and non-human) life. A simple etymological analysis of
the concept of bioethics will not provide a sufficient answer inorder to understand the concept. Thus, we have to lookelsewhere in order to grasp the meaning of bioethics.
A description of the discourse in bioethics might provide anadequate understanding of what bioethics is. Looking at thedebate about bioethics in Europe (especially in Germany), one
finds different questions that are discussed under the topic ofbioethics: Is cloning ethical? Should research on humanembryonic stem cells be allowed? What are the implications ofpreimplantation genetic diagnosis (PGD)? What are thebenefits and dangers of genetic engineering in plants? These
are the questions that are mainly discussed, when the word
1
Quite often these questions are“bioethics” is used.
accompanied by far-reaching speculations given that thesetechnologies are either brand-new (embryonic stem cellresearch, PGD) or not yet possible (cloning). Other questions
that deal with the protection of the environment or technologies
concerning contraception are hardly considered to be part ofbioethics. In all these cases, we deal with ethical questions
arising from new technologies, in particular with the morality ofgenetic engineering. A further look at the recent history ofscience and the origin of the concept of bioethics might give us
a more concrete idea about it.
Bioethics was first widely discussed in the late 1960s andearly 1970s. As all concepts that make their way into thescientific discourse, they are a concrete reaction on questions
in a field of society. 2 Bioethics was commonly conceptualized
as an answer to the innovations in the realm of medicine, whichgive rise to new questions. Tom Beauchamp and James
Childress’ book on the Principles of Biomedical Ethics, firstly
published in 1979, is still considered the standard textbook in
the field of bioethics, especially in the medical field and in theUSA. It bases bioethics in the medical context on four
principles: autonomy, non-maleficience, beneficience andjustice. Under the topic of autonomy, for example, informed
consent, confidentiality and privacy are crucial. The focus of thebook is slightly wider than the questions discussed under the
topic bioethics in Germany. It lies on ethical issues that arise
from modern medicine in general. 3
Bioethics in the narrow sense can be understood as acollective term for various questions that spring fromtechnological innovations in the fields of medicine, biology andlife-sciences: Ethics of health care answers questions genuine
to the different types of health care institutions, medical ethics
tackles ethical issues related to modern medicine, the ethics ofbiotechnological research such as embryonic stem (ES) cellresearch and cloning, and lastly environmental ethics deals withthe potential damage of modern technology to the environment.

Bioethics as the general term is subsumed under ethics, i.e. it is4
a branch of applied ethics.
The notion of bioethics encountered in the Philippines issignificantly wider in scope. Three books – by a medical doctor,
Dr. Alora, by a theologian, Fr. Miranda, and by a philosopher,Dr. Timbreza – will show that. In a small handbook in bioethics
Alora states bluntly: “Bioethics is the division of Ethics that
relates to human life or the Ethics of the life science andhealthcare, both delivery and research.” 5 Reading thisdefinition, one ponders about two things: Firstly, about theequation of “human life” and the “Ethics of the life science andhealthcare”. Depending on how one understands bioethics, thescope will be very different. Secondly, the above understanding
makes clear that there is not a single understanding of
bioethics, but that it strongly varies in different cultures.
Another book, entitled Pagkamakabuhay. On the Side of Life
written by Dionisio M. Miranda, attempts to offer a Filipino
6
Bioethics is not understood as annotion of bioethics.
application of principles to a certain situation, rather it isunderstood as a form of life embedded in its socio-culturalcontext that covers all aspects of life. Bioethics, understood as
our attitudes towards life in general, is rooted in a concrete
culture:“Filipino bioethics may therefore be seen as that part ofhuman reflection which explicates in a holistic way thesignificance of illness and health within the Filipino culture andcontext, the values involved in the threats to corporal existence,and the principles which must guide one’s activity in theaffirmation of personal life as embodied.” 7This notion of bioethics is quite far away from the abstract
principles and its differentiations suggested by Beauchamp andChildress. The common Western understanding of bioethics asa branch of applied ethics becomes arguable. 8
A last example refers to Florentino T. Timbreza’s bioethics
book that is praised in the foreword as “the first full-length9
textbook of bioethics in the Philippines.” A quick glance at thetable of content shows that it covers a wide range of issues
from abortion to suicide, from contraception and sterilization to
the mankind old questions of human sexuality. A range of
topics that goes well beyond what is in public and academic
discourse in Europe: neither contraception and sterilization nor
the whole range of human sexuality would be considered to bepart of bioethics as these questions are not arising from theprogress in science.
I do not claim that these books are representative of theFilipino understanding of bioethics. However, it is worth to ask
what these different accounts have in common that
distinguishes them from the Western perspective as describedabove: Firstly, the scope of all of these books is considerably
4

1

For a philosophical discussion of these bioethical issues in Germany,see my article: Bioethics: A view on the contemporary discussion inGermany compared to Asia. EJAIB, Vol. 16 (4), 2006, 125 – 130
2
Concepts do not pop up by chance in a certain societal and historicalsituation. Rather, they are the consequence of it. From the perspectiveof the Critical Theory of the Frankfurt School, one might wellunderstand bioethics (Life-ethics) as a reaction to the institutionalizationof life in general and a fear that life as such is subordinated byinstances that are more powerful such as the economic, industrial andadministrative system. Bioethics, then, would emphasize theimportance of human life against the power of these institutions. Butthat would be an entire different issue.
3
An interesting understanding that slightly deviates from the above, isprovided by the US American President’s Council on Bioethics: “To dobioethics properly, I suggest, means [...] undertaking fundamental
inquiry into the full human and moral significance of developments inbiomedical and behavioral science and technology. We must strive tounderstand the meanings of the intersection of biology and biography,
where life as lived experientially encounters the results of life studied
scientifically.”(http://www.bioethics.gov/background/council_second_term.html
accessed on March 28, 2008)

43

The focus of this paper will be medical ethics. For a discussion of thestructural difference between medical ethics and environmental ethics
see: O’Neill, Onora, Autonomy and Trust in Bioethics, Cambridge: CUP,
2002, p. 4ff. O’Neill points out, among others, that medical ethics
focuses mainly on the individual, while environmental ethics isconcerned with public harm and benefits.
5
Alora, Rosario Angeles Tan: A Handbook in Bioethics, Makati City:
Bookmark, 1999, p. 8
6Some clarification is needed when discussing “Filipino bioethics”. I am
certainly aware of the danger of cultural essentialism. When discussing
the Filipino notion of (bio-) ethics, I refer to a certain way of interaction
with reality that is dominant in the Filipino peninsula as described in thebooks quoted and some limited personal experience. I am especiallyaware of the danger of the nation as a group concept.
7
Miranda, Dionisio M. Pagkamakabuhay, p. 328
8Helga Kuhse and Peter Singer for example clearly point out thatbioethics is a branch of applied ethics. (Kuhse, Helga and Singer, Peter(eds.), Bioethics. An Anthology, Oxford: Blackwell, 1999, p. 1. I will later
return to this “Prolegomena for Bioethics from a Filipino-Christian
Perspective” (the subtitle of Miranda’s book) as it sheds light on theculturality of bioethics.
9
Andrew Gonzalez in this foreword to: Timbreza, Florentino, Bioethics
and Moral Decisions, Quezon City: C&E Publishing, p. xi

44

Eubios Journal of Asian and International Bioethics 19 (March 2009)broader. Secondly, there is significant less emphasis on
abstract principles or institutions, and lastly bioethics is notunderstood as a distinct scientific theory but – especially in thecase of Miranda – rather as a form of life. These differences
show the cultural relativity of the concept of bioethics. However,the philosopher – who cherishes nothing more than clear anddistinct concepts – cannot be satisfied with a blurry meaning of
bioethics and attempts to identify a workable notion.
3. The UNESCO Universal Declaration on Bioethics andHuman Rights (UDBHR)
Having such difficulties in understanding the term, one islooking for guidance of international bodies such as the
UNESCO, which recently under much ado adopted a resolution
on bioethics. 10 The declaration, published in 2005, is entitled11“Universal Declaration on Bioethics and Human Rights”.
UNESCO understands her role as one of “identifying universal
principles based on shared ethical values” (Preface). Stating
that, UNESCO commits herself to a view of ethicaluniversalism, i.e. that there are universally shared ethicalvalues, which she attempts to identify and turn into universallybinding principles. 12
Quite surprisingly, a definition of bioethics is not provided in
the declaration; not surprisingly given the above discussion of
the different understandings of bioethics. A look at the scope ofthe declaration, however, gives us a clearer idea of whatbioethics is: “This declaration addresses ethical issues related
to medicine, life sciences and associated technologies asapplied to human beings, taking into account their social, legal
and environmental dimensions.” (Art 1.1) Bioethics, thedeclaration suggests, deals therefore with ethical questions thatarise from (new) technologies within the scientific disciplines
concerned with human life in its biological function. 13 Moreover,the second and third paragraph of the preamble areemphasizing the “rapid development in science and technology”
and “rapid advances in science and their technologicalapplication” respectively, which change “our understanding oflife and life itself” and give raise to ethical questions. Looking at
the UNESCO homepage, the focus of bioethics gets even more
concrete.
“Stem cell research, genetic testing, cloning: progress in thelife sciences is giving human beings new power to improve ourhealth and control the development processes of all living
species. Concerns about the social, cultural, legal and ethicalimplications of such progress have led to one of the mostsignificant debates of the past century. A new word has been
14
coined to encompass these concerns: bioethics.”
In other words, according to the scope of the declaration andthis short description, bioethics is a field of ethics that reflects
on the development of new technologies in the field of scienceand technology. The scope of the UNESCO understanding of
bioethics is therefore akin to the Western understanding
10

In the drafting process, there have been encouraging and criticising
views expressed about the content of the declaration. John Williams
laments its lack in scope in health care somehow falling in between an
ethical, educational document for individuals and a legal document
addressed to states. (Williams, John R., “UNESCO’s Proposed
Declaration on Bioethics and Human Rights – A Bland Compromise,Developing World Bioethics, Vol. 5 (3), 2005, 210-215). A different view
takes Ruth Macklin who hails the political force of the document
although she criticizes that it might be too restrictive. (Macklin, Ruth,“Yet Another Guideline? The UNESCO Draft Declaration”, Developing
World Bioethics, Vol. 5 (3), 2005, 245-250)
11
http://portal.unesco.org/en/ev.phpURL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html(accessed on Jan 27, 2009)12
UNESCO is a secretariat to 194 member countries of the world, who
adopted the UDBHR unanimously. The term “United Nations” however
implies a commitment to an ethical universalism.
13
Further should be noted that the scope given by the declaration isanthropocentric. The welfare of animals and the biodiversity of nature
are only of importance as long as human beings are concerned.
14
www.unesco.org/shs/bioethics (retrieved on Dec 1, 2007)

sketched out above and does not mirror how bioethics isunderstood for example in the Philippines.
Looking at the content of the declaration, we can finddifferent principles mostly formulated along the line of Tom
Beauchamp and James Childress’s Principles of Biomedical
Ethics. A glance at Article 3 to 17, which deals with theprinciples of the declaration, can illustrate this. (The latter part,
Articles 18 to 25, is concerned with the application of theprinciples.)Articles 5 to 9 deal with the principle of autonomy under
different headings: Art. 5 states that the autonomy of a person
has to be respected, Art. 6 and 7 deal with informed consent
and the provisions concerning persons unable to consent. Art. 8
demands respect for personal integrity and Art. 9 put forward
the principles of privacy and confidentiality. Thus, the principle
of individual autonomy and its different subprinciples like
informed consent, privacy and confidentiality is given extensive
place.
The next group of articles, 10 to 16, is concerned, in one way
or another, with the principle of justice. These principles
demand for equal treatment of human beings regardless ofculture or religion (Art. 10-12), ask for solidarity and cooperation(Art. 13) and demand for equal access to the life-necessary
resources such as water and nutrition in general and to healthcare in particular (Art. 14-15). Finally, Art. 16 deals with the15issue of intergenerational justice. In summary, the principlesof the UNESCO declaration are concerned mainly withautonomy and justice. Incidentally, these two principles are theones that face difficulties when implemented in the cultural andsocial context of the Philippines for different reasons which will
be dealt with in the next paragraph.
Before turning to that question, a glance at the application of
the principles dealt with in the latter part of the declaration
merits attention. It can be read that bioethics in the declaration,
is mainly understood as institutional ethics. The scope of thedeclaration makes that clear: “This Declaration is addressed toStates.” (Art 1.2) 16 When it comes to the application of thesuggested principles, the main actors are again nation-states.
The declaration calls for “independent, multidisciplinary andpluralistic ethics committees” (Art. 19) to work towards theimplementation of the principles. Rules of conduct are given fortransnational practices (Art. 21) and international cooperation is
encouraged (Art. 24). In short, it is considered the task of theStates to ensure a responsible handling of new technologies in
the field of the life sciences.
In the following paragraphs, I will first show the problematicof such a narrow understanding of bioethics in the context of adeveloping country like the Philippines and then tentatively
show how a broader notion of bioethics can challenge thenarrow notion.
4. Filipino Bioethics’ contrast to the UNESCO Declaration
Bioethics, in the “Western” sense, is mainly based onprinciples. Especially the already mentioned principles of
Beauchamp and Childress play an important role. As
demonstrated in the above paragraph, the UDBHR has to beconsidered in scope as well as in content as part of theWestern type of bioethics: an institutional ethics which is guided
by abstract principles. This claim to universality, put forward
among others by the UDBHR, will be examined through some
aspects of Filipino bioethics. At the center of this examination is
the significance of autonomy and justice as well as the scope ofthe declaration.

15

The last article that is dealing with the principle (and not its
application) demands the “protection of the environment, the biosphereand biodiversity” (Art. 17)
16
In full, Art 1.2 states: “This Declaration is addressed to States. As
appropriate and relevant, it also provides guidance to decisions orpractices of individuals, groups, communities, institutions andcorporations, public and private.”Eubios Journal of Asian and International Bioethics 19 (March 2009)
Autonomy
There are mainly two cultural aspects in the Philippines that
undermine the Western notion of autonomy: the emphasis on
family and the Filipino view of the patient. As Angeles Tan Aloraand Joseph M. Lumitao put it in their critique of Western
bioethics: “The focus of Western bioethics is individual;
elsewhere it focuses on social units.” 17 Certainly, thePhilippines is part of elsewhere: The family is considered thebasic unit of society. The importance of the family is reflected
18This strong
as well in the Constitution of the Philippines.
notion of family fundamentally undermines autonomy andinformed consent, which is crucial for Western bioethics.
A second aspect that is at odds with the notion of autonomy
is the understanding of the patient. The family needs to takecare of the patient and to spare him from all sources of stress.
The family is the primary caregiver; sometimes the patient iseven exempted from deciding about the adequate treatment: 19“The sick family member accepts a role of dependency andpassive tolerance.” 20 A consequence of the importance of thefamily and the understanding of the patient is for example thatthe physician “talks to the relatives first [...] as if the patient21
were not present at all.” The notion of autonomy, informed
consent as well as privacy and confidentiality are either
marginalized or nonexistent at all.
One way of harmonizing the emphasis on autonomy in the
UDBHR and the lack of individual autonomy in the context of
the Philippines, is to apply the notion of autonomy to wholefamilies instead. Not the individual’s autonomy is considered,
but the familial autonomy. However, this attempt of rectification
stands in apparent contradiction with the declaration’semphasis of the person’s autonomy. 22 Moreover, thetraditionally vertical structures of Filipino society together with atrust in (for example medical) authorities run counter the very
23
notion of autonomy.
Justice
While in the case of autonomy, the inadequacy of theconcept can be shown clearly, it is not that straightforward
when dealing with justice. The most-promising way ofunderstanding the difference in the Western notion of justiceand the Filipino notion is to look at the different understandingsof morality.

17

Alora, Rosario Angeles Tan and Lumitao, Josephine M.: An
Introduction to an Authentically Non-Western Bioethics, in: Angeles Tan
Alora and Josephine M. Lumitao (ed.): Beyond a Western Bioethics:
Voices from the Developing World, Washington D.C.: Georgetown
University Press, 2001, p. 4
18“The State recognizes the Filipino family as the foundation of thenation. Accordingly, it shall strengthen its solidarity and actively
promote its total development.” (Art. XV, Sec. 1)
19Lumitao and Kuan describe the case of a 75 year-old active diabetic
female patient, who needs amputation of her right leg. The daughter
knowing about her mother’s opposition to the surgery urges thesurgeon not to inform the mother, and gives consent to the operation inplace of her. A proceeding, as Lumitao and Kuan rightly say, that iscompletely opposite to Western bioethics. (Lumitao, Josephine M. andKuan, Letty G.: The Family and Health Care Practices, in: Angeles Tan
Alora and Josephine M. Lumitao (ed.): Beyond a Western Bioethics:
Voices from the Developing World, Washington D.C.: Georgetown
University Press, 2001, p. 23)
20
Alora/Lumitao, An Introduction, p. 15
21
Lumitao and Kuan, p. 25
22„The autonomy of persons to make decisions ... is to be respected.”(Art 5). “Any preventive, diagnostic and therapeutic medical intervention
is only to be carried out with the prior, free and informed consent of theperson concerned.” (Art. 6.1)
23
Kuan and Lumitao put forward a case study about a stroke patient
treated by a orthopedic surgeon, a family friend, who is chosen notbecause of his medical expertise in the field, but rather because offamily ties The surgeon himself feels insulted when a nurse, noticing
the worsening condition of the patient, suggests to refer him to a
specialist. (Kuan/Lumitao, The Family and Health Care Practices, p. 29)

45“Filipino bioethics as a lived ethic does not focus on
individual consent to health care, individual confidentiality, or
individually articulated concerns with beneficence, caring or
truth-telling. The focus is on family – a social reality thatsustains a communal morality.” 24In this quote Alora and Lumitao construct an opposition
between an individualistic principle-based Western type of
25
This
bioethics and a person-oriented Filipino Bioethics.
understanding of bioethics, which we find as well in Miranda’s
Pagkamakabuhay, affects the principle of justice. The
responsibility towards people is perceived as much stronger,
than the ethical demand to follow an abstract principle. This
notion of mutual responsibility or gratitude undermines Western
26
egalitarianism. This notion of responsibility or indebtedness
towards the concrete other affects, for example, the allocationof scarce resources: A bed in an ICU will rather be to a person
to whom the physician feels indebted than to the one thatneeds it most. 27 On a more abstract level, we can see that thesocial web takes preference over abstract principles. 28
Scope of the declaration
The above discussion about autonomy and justice haveshown that the principle oriented bioethics, which is put forward
also in the UDBHR, has a universality deficit and is culturally
biased. Not only its content, but also its scope is culturally
biased in two regards: The scope “addresses ethical issues
related to medicine, life science and associated technologies asapplied to human beings” (Art 1.1) and it “is addressed toStates” (Art 1.2). In article 14 however, social responsibility
includes access to food, water, and health care. Regarding the
ethical issues addressed, a quick glance at the social reality of
the Philippines shows that the bioethical questions most facerelate more to social responsibility than to other issues raisedon the UNESCO homepage like stem cell research andcloning. 29 However, the topic of bioethics still appeals to people

24

Alora/Lumitao, An Introduction, p. 15„Filipino culture is person-oriented: Persons take precedence overabstract, impersonal issues or ideas.” (Alora/ Lumitao, An Introduction,p. 9) That is of course a wide ranging statement and for the Westernoutsider, who attempts to understand Filipino culture, still a source of
bewilderment.
26
Alora and Lumitao argue even more decicive: „In short, instances of amutual show of gratitude fail Western notions of egalitarianism. Issuesof fairness and justice may never become relevant, let alone decisive.”(An Introduction, p. 13)
27
Alora/Lumitao, An Introduction, p. 18
28
Concerning the issue of the allocation of scarce resources, a lot more
could be said. In an unfortunately very short article about the allocationof resources Alora and Lumitao writes that “the maldistribution of healthcare [...] is magnified in the Philippines.” (Alora, Rosario Angeles Tan
and Lumitao, Josephine M., “Allocation of Scarce Resources: Macro-,Meso-, and Micro-Level Concerns”, in: Beyond a Western Bioethics, p.
103) Moreover, they point out: “This situation [of the maldistribution]
may be considered unfair and unjust, or it may be regarded as theunfortunate outcome of more than moderate scarcity and the limits ofany moral approach to allocation.” (p. 104) On a personal note, I would
be critical with this type of defaitism. Given the resources of the upperclass spent for cosmetic surgery, further mechanisms of redistribution
could be put in place in order to alleviate scarcity in the health systemof the Philippines. However, this is ultimately a political question.
As a side note: Discussions with Austrian students at the University of
Vienna showed that the social web occasionally takes precedence overimpersonal principles in the Austrian health care system too. However,in the bioethics discourse the distribution of scarce resources according
to the social web is unanimously seen as unfair and a form of corruption
by these students.
29
Teaching issues such as stem cell research, PGD and cloning in mybioethics elective at the Ateneo de Manila University (2006/07), I
realized how far these issues are from my students. They pointed outthat there are much more pressing social issues, then questions
concerning the legitimacy of stem cell research or artificial reproduction
methods can be ignored.
25

46

Eubios Journal of Asian and International Bioethics 19 (March 2009)as the literature covering bioethics shows. Just the issues
addressed are different.
As pointed out earlier, a common Western understanding of
bioethics is one of an institutional ethics based on principles.
Not surprisingly therefore also in the context of the role of
UNESCO is that the UDBHR is addressed to States, and callsfor ethics committees, international cooperation and regulationof transnational practices. Such an institutional ethics is at odds
with the Filipino notion that bioethics is expressed “in lived
30
moral virtues.”
5. The Double Nature of Science and the Contextuality of
Bioethics
Having pointed out the points in the UDBHR, some general
remarks about the nature of science are needed to understandthe relativity of the concept of bioethics on and to prepare theground for what a Filipino bioethics could be. Science, first andforemost, has a double nature: On the one hand it claims tohave universal validity, it attempts to establish truth. On theother hand, it is rooted in concrete cultural situations; scientificdisciplines are reflections in a literal sense of questions arisingin a concrete social and historical context.
The discipline of bioethics might be a good example for thisdouble nature of science. 31 It is an example moreover thatshows a certain temptation inherent in science. The term
bioethics, as pointed out at the beginning, has its origin in
academic discussion in North America and Europe. It can beunderstood as a reaction to the rapid progress in medicine thatgave rise to new questions; more generally, bioethics, as it
appears to be, is a scientific discipline that attempts to solve
problems (or give guidelines) these problems that arise from acertain type of interaction with reality or a certain way of life.
But is bioethics a discipline at all? Onora O’Neill denies that:“Bioethics is not a discipline, nor even a new discipline; I doubt
whether it will ever be a discipline. It has become a meeting
ground for a number of disciplines, discourses andorganisations concerned with ethical, legal and social questions
raised by advances in medicine, science and biotechnology.” 32
O’Neill’s understanding of bioethics is culturally sensitive as
it does not understand bioethics as a discipline with a fixed
content, but rather as a formal meeting ground for different
disciplines. Depending on the issues in question, this meeting
ground can have different locations in different cultures.
However, she understands bioethics still as a basically scientificdiscourse (although it is influenced by media, politics and33
lobbyists as O’Neill points out ), which arises from progress
mainly in medicine.
However, referring back to the initial account of theunderstanding of bioethics in the Philippines, O’Neill’sunderstanding does not cover that. Moreover, given the healthsituation the large majority of the Filipinos are in, questions
arising from technological progress in medicine do simply notmatter. In a country where “seven out of every 10 [people] die
without ever seeing a doctor” 34 , where people in rural areas
have hardly access to medical care, technological progress is
30

Angeles/Lumitao, An Introduction, p. 4. To argue that the declaration
can be ignored as there will hardly be a tool to enforce it, fails to see its
main function. Declarations on the international level will decide about
how to allocate resources, which type of research will be funded andmore generally in which way science develops. In its regulative anddirective function the UNESCO declaration thus plays an important role.
31
Another example that comes to my mind is postcolonial studies.
Having studied in Germany, I did not even know that such a discipline
exists. It is a discipline that clearly arises out of concrete questions thatarise in a postcolonial setting and that cannot be answered by thestandard range of existing discipline which bring about the need for thisnew discipline.
32
O’Neill, Autonomy and Trust, p. 1
33
O’Neill, Autonomy and Trust, p. 1
34
Ombion, Karl G. and Azue, Ranie, The ‘Corporatization’ of the Public
Health System, in: Bulatlat, Vol. 5, No. 39, Nov. 6-12, 2005 (Online
accessible on: http://www.bulatlat.com/news/5-39/5-39-health.htm,
accessed Mar 28, 2008)

not the main issue that merits attention. 35 Putting it morebluntly: “Where people die of tuberculosis and leukemia andcan hardly afford the hospital bill (if they have access to a
hospital at all), ethical questions concerning stem cell researchor genetic testing can be neglected in good faith. Indeed, insuch a context the “ethics of biotechnology” has to give way toan “ethics of poverty.” 36 But what, then, could a bioethics in thePhilippines look like?
6. Remarks concerning Bioethics in the Philippines
Miranda formulates in Pagkamakabuhay the necessary
condition for a Filipino bioethics: “The test of bioethics as adiscipline lies in its responsiveness to the ethical problems of
37
With the above general remarks about
Filipinos today.”science in mind, we indeed have to look at the questions andissues that arise from life in the Philippines.
One attempt repeatedly made by Miranda as well as byAlora and Lumitao, is to look at the Filipino language in order toprovide a genuine approach of a Filipino bioethics. Concepts
such as loob (the within), hiya (embarrassment, timidity) andpakikisama (the seeking of harmony with others) are brought
into play to understand the distinctness of Filipino culture andlay the ground for a genuinely Filipino bioethics. Indeed,language is the house of being, as Heidegger would say, andan exploration of language might help in reconstructing Filipino
anthropology. However, cultural anthropology is different frombioethics. Although an ethics might have extensive
anthropological foundations such as Aristole’s or Spinoza’s, it
must retain some normative elements. If the term bioethics
should not become devoid of any content, then a certain
normativity – based on principles or virtues – is required.
Such bioethics is structurally different from the Western
bioethics I am familiar with. In the West, the driving force oftechnology brings about ethical questions that need to beanswered. We do not find this type of problematic here.
Bioethics – forced to give answer to concrete questions arisingin a concrete culture – would rather have to tackle more basic
issues about the fair access to medical services taking into
account the Filipino understanding of health and sickness.
Bioethics is not the constant attempt to put technologicalprogress within limits; rather, it should address cultural andsocial challenges. 38
7. Conclusion
The starting point of this paper was a certain conceptual
confusion about what bioethics is. Bioethics in the West, as
35

It sounds like a very bad joke, if a webpage that promotes tourism in
the Philippines writes the following: “Hospital expenses in thePhilippines are a lot cheaper compared to many other countries.
Filipinos have the privilege to get quick access to their medical needs
without spending so much every time they come and visit a doctor.”(http://www.wowparadisephilippines.com/ accessed on Mar 28, 2008)
36
Sahai, Suman, “The Bogus Debate on Bioethics”, Biotechnology andDevelopment
Monitor,
March
1997.
Onlineaccessible
on: www.agbioworld.org/biotech-info/articles/biotech-art/bogus.html on
Jan 27, 2009. Although I agree with Sahai to give priority to thepressing problem of poverty and that an echoing of the Western
bioethics debate in the Third World context is indeed bogus, I would beanxious to conclude that ethics is thus superfluous. For a thoughtful
critique of Sahai’s text see: Shiva, Vandana, Bioethics – A Third World
Issue, July 30, 1997, online accessible on: http://www.ratical.org/coglobalize/bioethics.html accessed Jan 27, 2009)37
Miranda. Pagkamakabuhay, p. 57
38
Critics might say that English is the wrong language to formulate sucha bioethics. However, in an international discourse, it will still be theonly way to make it heard. The books quoted above show as well thatsuccessful attempts were made to show the cultural bias of Western
bioethics and to work towards a different understanding of bioethics.
However, whether one wants to use the term bioethics for thatdiscipline (whether it has to be a scientific discipline at all) or not, thatremains open. (The advantage of calling it „bioethics“ to relate to aninternational discussion and scientific trend. The disadvantage is theconfusion it creates as bioethics becomes an equivocal terms with very
distinct meanings.)

Eubios Journal of Asian and International Bioethics 19 (March 2009)
commonly discussed 39 , is a result on the one hand ofaccelerated innovations in the realm of medicine and biology
and of the institutionalization of the field of medicine in the socalled First World. The UDBHR remains largely within theboundaries of a Western understanding of bioethics
propagating a principle-based form of bioethics centered on
autonomy and justice. Such an understanding is culturally
biased as seen in the discussion on Filipino bioethics. Bioethics
as understood in the Philippines focuses less on principles anddoes not give precedence on autonomy compared with culturalvalues such as seeking harmony with others and thedominance of the family over individual interests. Thus,
bioethics in the Philippines has to reflect on its rootedness in a
concrete cultural tradition, which is significantly distinct from theWestern principle-based bioethics. This conclusion, however,does not rule out a universalistic approach to bioethics, but it
asks to reconsider the culturally biased outlook of its
presumably universalistic principles.
Acknowledgements
An earlier version of this paper was presented at the 2008
PAP National Conference in Iba Zambales (Philippines) on April
9-11, 2008. I would like to thank the participants of theconference for their engaged discussion and especially Dr.
Cora Toralba for her reaction paper.
Bibliography
Alora, Rosario Angeles Tan. A Handbook in Bioethics, Makati City:
Bookmark, 1999
Alora, Rosario Angeles Tan and Josephine M. Lumitao. “AnIntroduction to an Authentically Non-Western Bioethics”, in: Angeles
Tan Alora and Josephine M. Lumitao (ed.): Beyond a Western
Bioethics: Voices from the Developing World, Washington D.C.:
Georgetown University Press, 2001, p. 3 – 20
Alora, Rosario Angeles Tan and Josephine M. Lumitao. “Allocation of
Scarce Resources: Macro-, Meso-, and Micro-Level Concerns”, in:Angeles Tan Alora and Josephine M. Lumitao (ed.): Beyond aWestern Bioethics: Voices from the Developing World, Washington
D.C.: Georgetown University Press, 2001, p. 102 – 107
Beauchamp, Tom L. and James F. Childress. Principles of Biomedical
Ethics, New York: Oxford University Press, 1979
Engelhardt, H. Tristram. The Foundations of Bioethics, Second Edition,
New York/Oxford: OUP, 1996
Hugaas, Jon Vegar, “The Relation between Normative and Descriptive
Ethics – A Consideration of Empirical Bioethics”, EJAIB, Vol. 19 (1),January 2009, 21-26
Kaelin, Lukas, “Bioethics: A View on the Contemporary Discussion inGermany Compared to Asia”. EJAIB, Vol. 16 (4), 2006, 125 – 130
Kuhse, Helga and Peter Singer (eds.), Bioethics. An Anthology, Oxford:
Blackwell, 1999
Lumitao, Josephine M. and Letty G. Kuan. “The Family and Health Care
Practices”, in: Angeles Tan Alora and Josephine M. Lumitao (ed.):Beyond a Western Bioethics: Voices from the Developing World,
Washington D.C.: Georgetown University Press, 2001, p. 23-29
Ombion, Karl G. and Ranie Azue. The ‘Corporatization’ of the Public
Health System, in: Bulatlat, Vol. 5, No. 39, Nov. 6-12, 2005 (Online
accessible on: http://www.bulatlat.com/news/5-39/5-39-health.htm,
accessed Mar 28, 2008)
Macklin, Ruth, “Yet Another Guideline? The UNESCO Draft
Declaration”, Developing World Bioethics, Vol. 5 (3), 2005, 245-250Mbữgua, Karori, “Is there an African Bioethics?”, EJAIB, Vol. 19 (1),January 2009, 2-5
Miranda, Dionisio M. Pagkamakabuhay. On the Side of Life.
Prolegomena for Bioethics from a Filipino-Christian Perspective,
Manila: Logos Publications, Inc., 1994
O’Neill, Onora. Autonomy and Trust in Bioethics, Cambridge: CUP,
2002
Sahai, Suman, The Bogus Debate on Bioethics, Biotechnology andDevelopment
Monitor,
March
1997.
Onlineaccessibleon www.agbioworld.org/biotech-info/articles/biotech-art/bogus.html on
Jan 27, 2009

Shiva, Vandana, “Bioethics – A Third World Issue”, July 30, 1997,
online accessible on: http://www.ratical.org/co-globalize/bioethics.html
accessed Jan 27, 2009
Timbreza, Florentino T., Bioethics and Moral Decisions, Quezon City:
C&E Publishing, 2007
UNESCO. Declaration on Bioethics and Human Rights, (Online
accessibleon:
http://portal.unesco.org/en/ev.phpURL_ID=31058&URL_DO=DO_TOPIC&URL_SECTION=201.html
accessed Jan 28, 2008)
Williams, John R.: “Unesco's Proposed Declaration on Bioethics andHuman Rights – A Bland Compromise”, Developing World Bioethics,
Vol. 5 (3), 2005, 210-215

Aesthetics in Ethics:
Narrative and Theoretical
Dimensions of Moral
Evaluation- Paolo Marino Cattorini, Ph.D.
Full Chair Professor of Bioethics,
State University of Insubria, Varese, Italy;
Former member, National Committee for Bioethics (Rome) andNational Commission for the Fight against Aids (Rome)
Email: paolo.cattorini@uninsubria.it
Postal address: via Vigorelli 2, 20090 Segrate (Mi), Italy
Abstract
A narrative ethics takes into account the biographical plot ofa moral agent, and the background stories, that lead the hopes
and offer the behaviour paradigms to daily choices. Ethicaltheories take root in the visions and tales of a just and good life.
Visions that we trust, without having the previous,
incontrovertible, intellectual evidence that they are true. Bothconceptual and emotional intelligence cooperate inunderstanding and evaluating the meaning of an action or the
dignity of an existence, just like the art criticism tries to grasp
the beauty of a work of art and to show the reasons why it looks
well done. The ethical discernment intertwines logical analysis,
symbolic interpretation, affective insight, literary creativity.
Key words: Ethics, aesthetics, narrative, medical dilemma,
moral evaluation.
The silence of the story teller
In the novel by Joseph Roth, Beichte eines Mörders erzählt
in einer Nacht, a murderer confesses his guilt, during one night.
Golubcik, who is telling in a restaurant his worrying experience,
makes a pause, a long pause 40 . He does not speak, drink, evenmove. One listener (the narrating voice), who reports thatmortal silence to the readers, records a strange anguish.
Golubcik had been bringing the audience out of the time,
introducing them in an eternally valid story, upon the eternallywavy waters of an endless sea. Now they were all left to themercy of that nocturnal silence.
Something like that happens to ethics, when the flow of thenarrative thinking stops and you feel the risk of playing themoralist, i.e of applying abstract and simplistic categories to thereality. Even worse, ethics, amputated and detached fromnarrative, loses its own identity, trying to arrogantly reach an
impossibile geometric exactitude. When something does not fall

40

39

There are of course exceptions seen in many authors.

47

Joseph Roth Werke, Bd. II, Verlag Allert De Lange, Amsterdam, undVerlag Kiepenheuer & Witsch, Köln, 1975 (Ital. transl. Milano,Bompiani, 1987, p. 90).

48

Eubios Journal of Asian and International Bioethics 19 (March 2009)

under a general law, Aristotle says 41 , it is the law which must
be corrected, and a decree has to be written following thenuances of the case, as the flexible list, mad of lead, used in
the construction of the city of Lesbo. Such a measuring list
adapts itself to the shape of the stones and it is not blocked in arigid form. Narrative is like this architect’s tool, mentioned by
Aristotle. It is the word we need, to confess faithfully our crimes.
Narrative in Ethics.
The French philosopher Pascal has once distinguished theesprit de finesse from the esprit of géométrie. It is unfortunately
an awkward geometrical deduction that goes into action, when
the famous principles of biomedical ethics (autonomy,42
are applied in abeneficence, non maleficence, justice)mechanical way, like a magic chemical formula, that could
transfer the diamond clearness of a theory to the anarchic,
chaotic and dirty world of living situations, where moral
dilemmas emerge from.
Here is the géométrie of the reasoning: in the major premiseof the moral syllogism stand theoretical principles; in the minor
one stands the historical description; the conclusion harvests
the safe moral truth. For example: stealing is morally bad (themajor premise taken from the pure heaven of some
philosophical intuition); Peter is stealing (the minor premise);Peter is doing evil (the conclusion).
The purity of simple, fixed, ahistorical, impersonal, universal,
comprehensive theories on one side; the confused andchanging field of individual stories, on the other side. Is this thereal relationship between these two domains? We would give anegative answer for several reasons.
First of all, there is a simple proof of the strict kinship (rather
than separation) and mutual belonging of the two dimensions.
The perennial aim of ethics is looking for a theory so generallysound that it might solve each single dilemma. This means that
individual stories have a special evaluating power: they are thetest bench of theories and force them to revise concepts, ideals
and rules. Every ethicist knows that in applying ethics there is asort of rebounding from the reality, to which the principles arebrought down, to the theory from which the principles originate.
This rebounding is such that the deformation stamped orconveyed from the reality to the principles may result in themodification of the theory itself. This phenomenon can be
explained in just one way: the two levels of understanding have43
the same root and nature .
Furthermore, the description of the action, to be evaluated,needs a narrative, to understand its meaning. Only if we know
the premises, the cultural background, the moral agent’s
intention, the historical consequences of a gesture, we canperceive the moral dimensions of what’s happening. An action
41

Nicomachean Ethics 1137 b (Ital. transl. Etica Nicomachea, Milano,
Rusconi, 1979, p. 256).
42
The famous book Principles of Biomedical Ethics, by T.L. Beauchamp
and J.F. Childress, Oxford, Oxford Univ. Press, 1979, 2001 (5th ed.),has raised several disappointments over the last years. See forexample E.R.DuBose-R.Hamel-L.J.O’Connell, Eds., A Matter ofPrinciples? Ferment in U.S. Bioethics, Valley Forge, Trinity Press Int.,
1994. Beauchamp himself, Principles and ‘Principlism’, in AA.VV., Le
radici della bioetica, Milano, Vita e Pensiero, 1998, 47-59, writes:“Principles, in the prima facie conception, should be understood less asnorms that are applied and more as guidelines that are interpreted andmade specific for policy and clinical decision making “(p.55). The“specification” of the principles is defined (quoting Richardson and De
Grazia): “the progressive filling in and development of the abstract
content of principles, shedding their indeterminateness and thereby
providing action-guiding content” (p.55). We would ask: where comesfrom the material with which we fill the principles, if not from stories andexistential metaphors? See also H.S.Richardson, “Specifying Norms asa Way to Resolve Concrete Ethical Problems”, Philosophy and Public
Affairs, 19, 1990, 279-310.
43
The theoretical presumption of building a rational, self-sufficientsystem of norms, based upon some a priori principle or truth, has been
criticized since the ‘50s: see G.E.M. Anscombe, “Modern Moral
Philosophy”, Philosophy, 33, 1958, 1-18.

is like a text, that can be interpreted just within its context andthat is why narrative, as Paul Ricoeur has written, is the firstlaboratory of moral judgement 44 . The narrative perspective isexactly the right point of view to see the whole identity of anaction. As an ethics consultant for health care staff, I am used
to advising my colleagues: before asking me if an action isgood or wrong, I ask you, please, to tell me the story, where
45
that action takes place .
Against the naive separation between description andprescription, between facts and values, in ethics we have torecognize that every narrative (which entails a description ofdetails and a course of events) is an interpretation. Who tells
the novel, decides what to say and what to omit, what deserves
larger or less attention, and the decision reflects the moral
stance of the observer, narrator or author and his ideal of a46
worthy vision . A value framework always orientates our sightand attention, so that we can see different things even if welook at the same object. As a moral evaluation implies anhistorical account of the events, so this depiction implies anethical perspective. No dissociation is possible between theobjective and subjective side of our sight 47 .
The necessity of tale-telling has not only to do with theminor, but also with the major premise of the ethicalargumentation. Ethical theories, concepts and abstract forms of
reasoning are rooted into visions of the world48(Weltanshauungen in Karl Jaspers’s words ), visions shaped
as original or germinal stories, as myths (in the richest sense),that tell the beginning and the end, the genesis, destiny androle of the human beings in the universe. We see the ethicalmyths as a plot linking together the symbols of good, we
believe in. Reciprocally, we see such symbols as narratives,
which are compressed and condensed, like a skein of cotton,that a story-teller might unravel again. Now, stories connect
moral symbols and ethical cyphers (cyphers of good, cyphers ofevil) as a music that binds notes and melodies, we love.
Stories, that we trust, without having the theoretical,
incontrovertible, undoubt evidence that they are true. Stories
that give us the vocabulary to describe, interpret and evaluate
the meaning of our biography and of our choices and deeds.
Stories that offer the criteria to balance, weigh and measure thedifferent effects, produced by an action (in a teleologicalapproach), or to compare and rank the conflicting duties andrights (in a deontological approach).
The distinction between pain and suffering is a good
example of this narrative reasoning. Pain can be measured,
44

For the notion of action as a text, see Paul Ricoeur’s philosophicalresearches, for example P. Ricoeur, Du texte à la’action, Paris, Seuil,1986 (Ital. transl., Dal testo all’azione. Saggi di ermeneutica, Milan,
Jaca Book, 1989) and Soi-même comme un autre, Paris, Seuil, 1990
(Ital. transl. Sè come un altro, Milano, Jaca Book, 1993). See also
P.Kemp, “Per un’etica narrativa. Un ponte tra l’etica e la riflessione
narrativa in P.Ricoeur”, Aquinas, 31, 1988, 435-458.
45This is also the incipit of my book Bioetica e cinema. Racconti dimalattia e dilemmi morali, 2nd ed., Milano, FrancoAngeli, 2006.
46
S. Chatman, Story and Discourse, London, Cornell Univ, Press,
1978 (Ital. transl. Storia e discorso. La struttura narrativa nel romanzo e
nel film, Milano, Il Saggiatore, 2003).
47
See H. G. Gadamer’s hermeneutic lesson in Wahrheit und Methode,Tübingen, Mohr, 1972 (Ital. transl. Verità e metodo, Milano, Bompiani,
1983); D.C.Thomasma, “Clinical Ethics as Medical Hermeneutics”,
Theoretical Medicine, 1994, 15, 93-111; P. van Tongeren, “The
Relation of Narrativity and Hermeneutics to an Adequate Practical
Ethic”, Ethical Perspectives, v.1, n.2, June 1994, 57-69; R.A. Carson,“Interpretive Bioethics: the Way of Discernment”, Theoretical Medicine,11, 1990, 51-59; R.A.Carson, “Interpretation”, in W.T.Reich, Ed., Enc.
Bioethics, New York, Simon & Schuster, 1995; R.A.Carson, “Medical
Ethics as a Reflective Practice”, in R.A. Carson-C.R.Burns, Eds.,
Philosophy of Medicine and Bioethics, Dordrecht, Kluwer Acad. Publ.,
1997, 181-191; T.S.Chambers, “The Bioethicist as Author: The Medical
Case as Rhetorical Device”, Literature and Medicine, 13, n.1, Spring
1994, 60-78.
48
K. Jaspers, Psychologie der Weltanshauungen, Berlin, Springer,
1925 (Ital. transl. Psicologia delle visioni del mondo, Roma, Astrolabio,1950).

Eubios Journal of Asian and International Bioethics 19 (March 2009)
suffering has to be narrated. Pain is not exactly suffering, evenif pain always causes human beings to suffer. Like all
symptoms of somatic illness, pain has a physical dimension and
it is affected by psychological factors. But when pain is felt by aperson, it is always “suffered” and therefore it has also an
ethical meaning, because it is always interpreted as part of anarrative: pain as punishment or blessing, revelation ordisaster, moral challenge or absurd event. Suffering is,
precisely, a feeling and a vibration of the whole person, and it
challenges the reasons of hope and the myths of justice, which
our moral life is founded on 49 .
Therefore applying ethics requires narrative work. The task
is to establish a relationship between two stories: the ideal of agood life and the events of our concrete life. In other words, theaim is to build a bridge between the paradigm of a just society,the trusted myth of a peaceful proximity, on one side, and, on
the other side, the concrete promise of caring for other persons.
A promise that we have made in our history and that constructs
our moral identity, because it represents the ipse, the self we50
have decided to be .
The moral agent goes to and fro between two narrative
levels: background tales (stories representing the destiny of
mankind and describing the features of a just, peaceful society)and individual tales (stories of our personal development, ofwhom we have been, we are, we dream to become). Great
tales give universal light and offer reasons of hope to the little
ones. Little tales test the great ones, compel them to expand
and to encompass new variations. This kind of effort resembles
a literary exercise and requires, as we shall say further, someaesthetic competences. As Ronald Dworkin has exactly written,
when we take a bioethical decision, we do not simply consider
which behaviour (out of the range of alternatives) maximizes
pleasure and minimizes suffering, nor which behaviour adheres
most to impersonal rules of conduct. Instead, we ask what themost beautiful action is, that is, whatever ensures the mostcoherent progression or conclusion of our human experience. It
happens as if we were writing, as authors, the next chapter ofour story, moving toward a good end, looking for a niceconclusion and wondering how to connect the narrative unity of
our life with the original story, that guides our last hopes 51 .

49

E.J. Cassell, The Nature of Suffering and the Goals of Medicine, New
York-Oxford, Oxford University Press, 1991 commented by P. Cattorini,
La morte offesa. Espropriazione del morire ed etica della resistenza al
male, Bologna, Dehoniane, 2006 and P. Cattorini, “Narrating Pain: The
Role of Medical Humanities”, Eubios Journal of Asian and International
Bioethics, v. 16 (6), Nov. 2006, 177-181.
50
In Ricoeur’s terms, it represents our selfhood, notwithstanding thechanges of our body, character, biological features, social positions, i.e.
the changes of my sameness. See also J. Verstraeten, “Narrativity andHermeneutics in Applied Ethics, Ethical Perspectives, v.1, n.2, June
1994, 51-56; M.H. Waymack, “Narrative Ethics in the Clinical Setting”,
Making the Rounds, v.1, n.15, April 8, 1996 , 1-4; R. Zaner, Ethics andthe Clinical Encounter, Englewood Cliffs, Prentice Hall, 1988.
51
R. Dworkin, Life’s Dominion. An Argument about Abortion,
Euthanasia and Individual Freedom, New York, Knopf, 1993 (Ital.
transl., Il dominio della vita. Aborto, eutanasia e libertà individuale,
Milano, Edizioni di Comunità, 1994): we worry about the effect that the
final stage will have on a person’s entire life, just as we would worry
about the conclusion of an artwork, an artistic text, or the final scene ofa play. Life is to be evaluated as though we were criticising a bad
ending that ruins an entire piece of literature that we had enjoyed until
then. See also A.MacIntyre, After Virtue. A Study in Moral Theology,
Notre Dame, Univ. Notre Dame Press, 1984 (Ital. transl. Dopo la virtù.
Saggio di teoria morale, Milano, Feltrinelli, 1988); P. Cattorini’“Introduction”, Bioetica e cinema; and J. Good Byron, Medicine,
Rationality and Experience: An Anthropological Perspective,
Cambridge, Cambridge University Press, 1994 (Ital. transl., Narrare lamalattia. Lo sguardo antropologico sul rapporti medico-paziente,
Torino, Edizioni di Comunità, 1999). It is interesting J.D.Lock’s article,“Some Aspects of Medical Hermeneutics: the Role of Dialectic andNarrative”, Theoretical Medicine, 11, 1990, 41-49.

49

Narrative and Ethical Theories.
We could make several examples of the role played bystories and narrative metaphors in philosophy. There is thestory of the war of all against all behind Hobbes and somelibertarian versions of modern contractualism 52 . There is themyth of care behind some feminist ethical critiques of thebiomedical principlism. There is the Jewish memory of theliberation from Egypt behind the ideal of covenant used todescribe patient-physician relationship 53 . Generally speaking,there are some dimensions of the ethical truth, that can becaught and express only in this kind of narrative and symbolic
language: the Enlightenment believed in the victory of thereason over the past obscurantism, as a sun rising over the
power of a night that has been making a slave of free person;
even Hegel’s Phenomenology of the Spirit may be viewed as
54
a romanced story of the conscience .
Ethics is moral philosophy and what we discover in applying
ethics reveals a truth, that regards the whole Western
theoretical enterprise 55 . As Nietzsche once said, the newborn
Greek philosophy has embarked once forever the preexisting
wisdom of myths upon the Platonic boat, even if the theoreticalthought presumed to get rid of symbols and narratives.
Some comments on Plato’s works may be useful andespecially on his “non written doctrines”, that dealt with the“Good” and, as the most precious thoughts, were reserved for56
the personal oral education of the disciples . Plato’s teachingdoes not authorize to interpret philosophy as a one-way
passing from mythos to logos, as a transformation, that does
not leave rejects and that undervalues the former kind of
discourse as pre-philosophical or even anti-philosophical.
Actually “Plato regarded all his writings as forms of myth” 57 as
any writing, because of its inherent limits, cannot keep andexpress every kind of truth. The rigorous dialectic concepts,
coined for the pure noesis of the unchangeable and eternalbeing, do not fit the singular, becoming, hystorical and ethicalcontents of life.
Logos and mythos, which perform different, complementaryfunctions and which are the two sides of the same passion fortruth, have to be understood as “the systole and the diastole” of58
the Platonic philosophy , and generally as the two wings andways of the same research about the sense of life. Researcheach time takes the form of thinking through images (myths,
symbols) or through concepts (theories). The myth requires aninterpreter, who could analyse it and translate in concepts; the59concepts need the work of rediscovering their mytical core .
Bioethics itself recognizes its debt toward both narrative andtheoretical thinking, as two aspect of the same effort to givereasons why an action is good or wrong, just or unjust. There
are narrative elements in moral theories, as there is logicalcoherence and evaluative criteria in stories. Every side corrects
and integrates the other one, just like literary criticism judges
the likelihood, the coherence, the originality, the significance ofa novel, and on the contrary a good novelist opens new
narrative worlds, styles, atmospheres, that break and renew the52

W. T. Reich, “Alle origini dell’etica medica: mito del contratto o mito dicura?”, in P. Cattorini – R. Mordacci, Eds., Modelli di medicina, Milano,
Europa Scienze Umane Ed., 1993, pp. 35-60.
53
W.F.May, The Physician’s Covenant, Philadelphia, Westminster
Press, 1983.
54
J. Hyppolite, Genèse et structure de la “Phenomenologie de l’Esprit”
de Hegel, Paris, Aubier, Montaigne, 1946 (Ital. transl. Genesi e strutturadella “Fenomenologia dello Spirito” di Hegel, Milano, Bompiani, 2005).
55
We have deepened these aspects in P. Cattorini, Un buon racconto.
Etica, teologia, narrazione, Bologna, Ed. Dehoniane, 2007.
56
G. Reale, “Platone”, in: Fondazione Centro Studi Filosofi di Gallarate,
Enciclopedia Filosofica, Milano, Bompiani, 2006, v.9, pp. 8670 ss..
57
Ivi, p. 8696.
58
Ivi, p. 8697.
59
For the notion of blank metaphor, hidden between the lines oftheoretical concepts, see J. Derrida, Marges – de la philosophie, Paris,
Minuit, 1972 (Ital. transl. Margini della filosofia, Torino, Einaudi, 1997).

50

Eubios Journal of Asian and International Bioethics 19 (March 2009)

old philosophical definitions and the aesthetic criteria of literary
elegance.
Coming back to what we said about myths, visions and60
symbols of a good life , we could precise that theories function
as intellectual translations, abstract summaries, written in aclear, simple, impersonal language, of the narrative
Weltanshauungen, that we believe in. These visions attract ourdesire and motivate our own moral behaviour 61 . They are thegood breeding ground, where our key moral words bloom 62 andwhere we have to return, whenever a concept, prima facie
unequivocal, is interpreted and employed in opposite manners.
It happens for example when the terms “mercy” or “dignity” areused both to defend and to oppose voluntary euthanasia; it also
happens when two neo-Kantian philosophers fight each otherregarding autonomous suicide, even if both try to apply thesame rule: treat the humanity in yourself and in others always
as an end and never only as a mean. To understand what you
intend by a theoretical key-word, you need to tell the story fromwhich you have taken it out.
63
betweenBy reemploying the distinction made by Hadot
philosophy (philosophical life) and philosophical discourse, wewould say that applied ethics, the art of applying ethics, entails
the skill of imaging, interpreting, evaluating and realizing goodactions, while the theoretical ethics is the intellectual reflection
aimed to build a logically coherent structure where rules,
principles and general theories keep their own places andestablish justified relations. Now, from our bioethical point ofview, the abstract discourse is and has to be at the service ofthe concrete dealing with moral problems and with the crisis ofhuman existence. Theory comes from a living experience andhelps the life. If life is lost, theory itself ruins. But the two things
are not separate circles. Making philosophy and philosophicallyliving, defending an ethical theory and evaluating a fragment oflife are two dimensions of the same enthusiasm for a true life.
Faith and reason
One of the consequences of our thesis is the collapse ofanother abused dissociation: that one between faith andreason. We would rather suggest that every ethical theory is toan original story or vision what a concept is to a metaphor andwhat logical justification is to faith. The abused distinction
between religious and secular ethics, between sanctity andquality of life, between ethics-with-absolutes (based upon somefaith) and ethics-without-absolutes (based upon the reason)should leave room for the recognition that faith is an essential
element of the moral experience and of everybody ethicaldecision, if faith is defined as the credit given to the narrative
vision, that offers the value framework of our daily life
perceptions and that represents the paradigm to which wecompare the specific situations of our biographical journey.

60

A. MacIntyre, After Virtue. A Study in Moral Theory, Notre Dame,
Univ. Notre Dame Press, 1984 (Ital. transl. Dopo la virtù. Saggio diteoria morale, Milano, Feltrinelli, 1988).
61
It is useful the distinction between categorical imperatives anddesires made by B. Williams, Moral Luck. Philosophical Papers 19731980, Cambridge, Cambridge Univ. Press, 1981 (Ital. transl. Persone,carattere, moralità, in Sorte morale, Milano, Il Saggiatore, 1987, pp. 931)
62
As R. Rorty, Contingency, Irony and Solidarity, Cambridge,
Cambridge Univ. Press, 1989 (Ital. transl. La filosofia dopo la filosofia,
Bari, Laterza, 1990) has clearly stated, once we have chosen our moral
vocabulary, the theoretical game is already decided. The key, moral
debate does not entail ascribing an unequivocal theoretical foundation
to an assertion; it lies in comparing different vocabularies, expanding
the range of perspectives, identifying new moral ties and showing theability to identify and take a liking to the actors involved. Given thatanything can appear bad or good after a new, different description, an
opposition between assessment and narrative, moral and aesthetic, is
not very useful.
63
P. Hadot, Exercices spirituels et philosophie antique, Paris, Albin,
2002 (Ital. transl. Esercizi spirituali e filosofia antica, Torino, Einaudi,
2005).

As there is no reason without a vision, and concept without ametaphor, that lies behind it, then the task of ethics is to reflect
upon the visions and metaphors, that seem trustworthy. Ethics
is not a knowledge that is intellectually pure and void ofassumptions. It is rather the critical analysis of the cyphers andnovels, that interweave our life and give us a sense for living
well and doing good.
Jaspers, who affirmed that everyone, religious or not, readthe transcendency (the principle of being) through existential
cyphers, distinguished between a revealed and a philosophicalfaith (philosophische Glaube). The two stances are not eachother in a brutal confrontation (as it seems when pro-life andpro-choice positions fight in the moral arena), but areconnected in a common research and cultural challenge. Who
believes in a Revelation should admit that his faith is notessential for all the human kind; he may announce a Gospel,but he cannot wait for others following his belief. The
philosophical believer, on the other side, should recognize thatthe faith (which he feels so alien to his areligious nature) is forsomeone else a choice of truth coming from an unknown
origin 64 .
It happens as all of us were marching, in a tiring and risky
exodus, toward an happy and worthy land, toward a liberated
home, that lights our hope and demands our trust in apromising destination, in something valuable, belonging to thisearthly human life, that has to be faithfully embraced, even in
the most complete ignorance of the consequences 65 .
Narrating the emotions and affections
Clinical bioethicists run several risks to meet with adisappointment, when they try to apply some spreading ethicalconcepts to bedside situations. We have in mind, first of all,some emphasis on autonomy. Some streams of contemporary
bioethics, especially in the Anglo-analytical stream, havedescribed a moral agent that does not exist in the real world: an
isolated, atomistic individual, who looks for solutions for all
people and implements the (presumed) best decision, in animpersonal nowhere place, hidden behind a veil of ignorance,
free
from
passions,
affections,traditions,
relevant
66
relationships . The so-called autonomous person tries to follow
coherently a detached, intellectual reasoning, aimed to fulfill
general principles, or to maximize benefits and minimize evils
for all or to reach the largest consent among mature, individual,
67
self-conscious subjects .

64

K.Jaspers, Der philosophische Glaube angesichts der Offenbarung,
München, Piper, 1962 (Ital. transl. La fede filosofica di fronte alla
rivelazione, Milano, Longanesi, 1970, pp. 726-77).
65
B. Williams, Morality: An Introduction to Ethics, Cambridge,
Cambridge Univ. Press 1972, Canto Book Series 1993 (Ital. transl. La
moralità. Un’introduzione all’etica, Torino, Einaudi, 2000, p. 78).
66
In this perspective, Bernard Williams (in his criticism of T.M. Scanlon
and J. Rawls) has rightly written that contemporary ethics needs a
moral psychology: see B.Williams, Problems of the Self, Cambridge,
Cambridge Univ. Press, 1973 [Ital. transl. Problemi dell’io, Milano,
Mondadori, 1990]. We would add that contemporary clinical bioethics
has almost completely lost one aspect of its generating soul. An
emotional soul represented by pioneers like W.Gaylin, Talking is Not
Enough: How Psychotherapy Really Works, Brown, New York, 2000; Id.
The Meaning of Despair, New York, Science House, 1968 (Ital. transl. Il
significato della disperazione, Roma, Astrolabio-Ubaldini, 1973); Id.
“Nondirective Counseling or Advice: Psychotherapy as Value Laden”,
Hastings Center Report, v.30, n.3, May-June 2000, 31-33. Eric J.
Cassell, Talking with Patients (Cambridge-London , The MIT Press,
1985, 2 voll.) is another brilliant example of this attitude.
67
For a counterproposals, see the following P. Cattorini’s articles: “TheDesire for Children and the Experience of Illness. A Christian Ethical
Perspective, I supplementi di Tumori, v.3, n.3, S171-S175, 2004;“Application or Interpretation? The Role of Clinical Bioethics Between
Moral Principles and Concrete Situations”, Analecta Husserliana, LXXII,
2001, pp. 99-115; ”Clinical Bioethics. Identity, Role, Aims”, Medicina nei
Secoli - Journal of History of Medicine, 13/1, 2001, pp. 187-197;”Moral
Norms and Hermeneutics in Clinical Bioethics”, Medicina nei Secoli Journal of History of Medicine, 13/1, 2001, pp.199-209.

Eubios Journal of Asian and International Bioethics 19 (March 2009)This rationalistic attitude undervalues what actually moves
people to act, i.e. motives and passions:“It treats the rational content of speech and argument without
regard to the engaged concerns that incite both speech andaction. It by and large ignores mores and customs, sentiments
and attitudes, and the ‘small morals’ that are the bedrock ofordinary experience and the matrix of all interpersonal relations.
It by and large ignores real moral agents and concrete moral
situations, preferring the abstraction of the hypostasized‘rational decision maker’ confronting the idealized problem
needing to be solved [...] Though originally intended to improve
our deeds, the reigning practice of ethics, if truth be told, has, at
68
best, improved our speech”
Little attention is paid to the real phenomena of the moral
experience, to the stories we live and believe in, to the symbols
of good that make the history of my life my moral history, to theemotional turbulences (like the sense of guilt, of debt, ofshame) that give birth to and accompany one’s own personal
ethical conflicts. Little importance is given to the signs of themutual dependency that in childhood has marked once forever
and that everyday marks one’s own moral attitude.
From a narrative point of view, this perspective has to be
severely criticized. First of all, if “individual” moral agent means
someone not divided inside himself and divided from everyone
else, this model of individualism is nothing but an illusion, notonly because we grow up and survive thanks to others’ helps,
voices, gestures 69 , but also because we keep an ethical arena
inside ourselves, an arena where different voices, affections,thoughts, emotions hold a dialogue each other. An internal
theatre, where diverging characters play their roles in search fora true, happy solution of the adventure of their and our own life.
They are (using the title of a famous Pirandello’s theater pièce)
characters looking for an author and for a convincing plot. In
other words, the ideal of mental democratic and interdependent
integration seems to be more realistic and fundamental than the70
abstract request of autonomy .
Second point. “Affections blind the reason”, said an old andwrong sentence, that consequently condemned as irrational theemotional waves of the literary genre and privileged theimperturbable, detached style of a philosophical treatise.
Unfortunately for these intellectualistic premises, interpretingour desires and affections is the only way to catch which might
be our good action. Consequently, empathizing with others’
emotions is the only way to understand what they feel, hope,want and to collect useful elements to ethically evaluate their
behaviour.
This hermeneutical attention requires a narrative attitude,
because desires and emotions are not arbitrary and irrational
explosions, but are the proper reaction to a personal situation,
where our reason grasps something true or false, meets anenchanting or a disgusting revelation, encounters a benevolent
or a cynic face of the world. The emotions are turbulent
opinions as the moral opinions are emotions expressed ingeneral statements. A reason lies inside the desire, even when
it is ambiguous, opaque, savage. A vision of good lies inside an

68

L.R.Kass, “Practicing Ethics:Where’s the Action?”, Hastings Center
Report, 20,1, Jan.-Feb. 1990, 5-12. See also the comment by R. Hamel
in Bull. Park Ridge Center, Sept. 1990, 42-43.
69
For these reasons, feelings of gratitude and responsibility are theliving core of our moral awareness. We depend on others anddependency does not lead to heteronomy, but instead to the only kindof autonomy one can build and enjoy. The borders among persons are
not so complete and definite as some moral theories guess. ”The
opposite of autonomy [...] is not dependency but heteronomy” , write
J.Holmes and R. Lindley, The Values of Psychotherapy, London,
Karnac Books, 1998, p.7.
70
See this proposal by R.D. Hinshelwood, Therapy or Coercion?Does
Psychoanalysis Differ from Brainwashing?, London, Karnac Books,
1997.

51

emotion, even when it is wrongfully directed, misinformed,
71
unripe .
A person looking for what to do in a dilemma andinvestigating what kind of agent (of father, mother, or citizen) he(or she) wants to be, is committed to listen to his emotions, justto decide which gesture fulfils in the same time his desire ofhappiness and of justice, so that the good action, that he andonly he must do in that situation, could honour his aspiration to
enjoy his life and to promote the wellbeing of all the others. As
ethicists, we have been wrong to leave the topic of desires andaffections to psychologists. The most important moral decisions
in our life (to marry or not, to have child or not, to terminate one
treatment or not) are not taken, balancing consequences in animpersonal way, but opening and promoting the good side ofour desire, letting new textures of existence and new narrative
ways flourish from the emotional waves that suprisingly drive us
from behind.
Narrating is one of the most powerful thinking tools for taking
out the meaning of feelings, for showing their generating
motives, for imaging an authentic destiny of them 72 . By help ofnarratives we can ask the main question: what do emotions anddesires actually disclose to us? What people, witnesses,
proxies, creditors or betrayers do they summon? What gesture
do they claim? What world do they dream? Emotions are
essential elements of a moral life and of a sound ethics,
because they are symbols of a whole moral attitude andfragments of a story, that has still to be completely imaged,
understood and realized.
Aesthetics in ethics
We have assimilated the moral action to a text, who needs acontext to be understood and evaluated. Now, a literary text likea novel is but an example of a work of art. Therefore the final
step of our discourse intends to assimilate the applied ethics(bioethics, for what it concerns us) to a sort of art criticism, thatis the intriguing enterprise which tries to perceive the quality ofan artistic production and to give reason of its level of beauty.
Why do we need aesthetics in ethics? Because the goodaction has an intrinsic individual feature: it is a concrete
gesture, that asks that moral agent to be done in that way, inthat specific context, in the light of that existential story. It issomething that we, and only we in such a manner can make,because it is the deed that honours and expresses our personaldesire of justice and good, giving an original sense to theemotions and affections, that surprisingly has enchanted ourwill.
When we decide to implement a good action, we don’t obey
an external, impersonal, abstract order, but we take thedecision to mould in the best way our personal identity, toshape our biographical unity, to embody our ideal of dignity,
love, society. An ideal that we feel worthy of praise and we trust
as a vision, a narrative, that deserves the credit of our whole
life. From this point of view, the ethical decision looks like aliterary exercise: to put together and coherently interlace thestory, we are, and the guiding story, we esteem worthy of ourcommitment.
We don’t know what goodness is, before perceiving it into
the concrete, historical figures of deeds, that symbolically
represent an entire attitude towards our life, others’ rights, thehope in a better world, the sense of living. We can escape theappeal of these practical choices or we can consent to them,
image their development, reflect upon them and, in positive71

M.C. Nussbaum, Poetic Justice. The Literary Imagination and Public
Life, Boston, Beacon Press, 1995 (Ital. transl. Il giudizio del poeta.
Immaginazione letteraria e vita civile, Milano, Feltrinelli, 1996).
72
This is true also from a psychoanalitic point of view. See A. Ferro, La
psicoanalisi come letteratura e terapia, Milano, Cortina, 1999 and R.
Schafer, Retelling Life. Narration and Dialogue in Psychoanalysis , New
York, Basic Books, 1992, commented by P. Cattorini, La morale dei
sogni. Lo statuto etico della psicoanalisi, Bologna, Dehoniane, 1999.

52

Eubios Journal of Asian and International Bioethics 19 (March 2009)

case, we can decide to implement them and go to see whatkind of truth they open.
This discerning work is not so different from the engagementof an artist, who has felt a fascinating promise in the sequenceof colours, lines, words or musical notes, he has perceived. The
beauty, he is searching, is hidden right there and for no reason
he would lose its traces. Therefore he starts listening carefully
to those signs and obeying the meaningful world, they keep
inside. The creative efforts test new ways, perspectives,
attitudes and forms of relationship between the artist and thematerial elements, he can reshape 73 .
Now, if making a good action is like producing a work of art,
then the ethical evaluation is quite similar to the art criticism,that tries to discover the reason why a work is well done. When
we reflect upon the reasons why a kind of existence is morally
worthy or why a deed is ethically good, we cannot avert oureyes from the individual object of evaluation, because
intelligence and emotions, sense and sensibility (to quote thetitle of a famous Jane Austen’s book) cooperate to catch thisvalue dimension. We can use general criteria of discernment,
often obtained and extracted from the aesthetic tradition, likethe concept of proportion, but their meaning cannot be fixed
once for all a priori, and it has to be referred to the individual74
issue, which is the focus of the judgement .
In other words, something is good if it satisfies theexigencies of both our intellect and desire. The former gives
universal laws, but it cannot reach the individual. The lattergrasps the individual but does not possess certain andcomplete rules, that guarantee a firm deduction. If an ethicallaw exists, it has to be the law of that individual person andaction. At the same time, each moral agent makes use of
intellectual principles to distinguish in front of all the just and theunjust, the good and the wrong. Like the “finality without aspecific aim” (Zweck-mässigkeit ohne Zweck) in Kant, a norm
exists and seduces us, but it inextricably lies in concrete,individual and historical situations and cannot be translated in
univocal, universal concepts.
Our effort of moving the good closer to the beauty and toaccost the good gesture to the well done picture has several
authoritative precedents 75 :73

L. Pareyson, Estetica. Teoria della formatività, Milano, Sansoni, 1974
has written that the artist follows obediently an idea in deciding what to
do with the first shapes of the concrete work he is realizing. Where
comes this idea from? From the same work that does not yet exist andthat notwithstanding attracts his desire. Therefore we may talk of astringent legality in artistic action. It is true that a successful work is“fitting to itself” and nothing beyond itself, but it is also true that artistic
invention is guided by the same form which, if it succeeds, produces.
The piece of work acts even before existing, it is formed and it isforming together and it does not reach being formed if it has not been
forming. The piece of work therefore summons to itself the action of theartist, action which could remain inferior to the summoning, if it does notfollow faithfully the rigorous internal legality which will constitute thebeauty of the work. Such a law, which is produced with the work, andwhich together counts as a judging criterion of the artistic gesture, cantherefore be said to transcend the concrete action, since the artist does
not invent it despotically, but also discovers it, brings it to light andobeys it.
74
The Neoscholastic aesthetics recognized that this double element is
at work, when we employ terms like proportionate, that is one of theclassic features of the beautiful work of art (integritas, claritas, debita
proportio) and it is, not surprinsingly, one of the most frequent
adjectives in bedside ethics, when we talk, for example, of
proportionate forms of care. For the Neoscholastic position see S.
Vanni Rovighi, Elementi di filosofia, Brescia, La Scuola, v.II, cap. XII “Il
bello”, pp. 201 ss. For contemporary aesthetic criteria (like originality,
meaningfulness, coherence, wholeness, materiality, vitality, truthful
dissonance) see A. Ferrara, L’eudaimonia postmoderna. Mutamento
culturale e modelli di razionalità, Napoli, Liguori, 1992 and A.C. Danto,
The Transfiguration of the Commonplace.A Philosophy of Art,
Cambridge-London, Harvard Univ. Press, 1981.
75
The term “well done” fits better than “beautiful” the contemporary
artistic sensibility, because several “intractable” artists have reminded
us that beauty is not their aim and it has not always been the essential
feature of a excellent work of art. See A.C. Danto, The Abuse of“the idea of an identity or of an affinity of the beauty with thegood, probably present already in Socrates’ thinking,predominant in in Plato […], rejected by Aristotle […], reaffirmed
by Plotinus […], shows such a strong vitality that it appears
again in Shaftesbury’s ethics or aesthetics, and that it
influences Schiller’s ethics or aesthetics and the Romantic
poets’ and thinkers’ concepts” 76 .
Linguistic and etymologic studies have underlined therelationship of the beauty with the ideas of moral greatness andperfection and viceversa of the ugliness with the image of what
is morally shameful or base. 77
We can guess an immediate objection: the fall to a blind
subjectivism 78 . We would reply that our hermeneutical,
aesthetic and narrative stance does not condemn us to an
empty relativism, because both aesthetic and ethicaljudgements are not simply irrational, excited, sensorial
reactions. They are not a mere preference of taste. On contrary
they both deal with values, that claim universal approval. It istrue that, when we admire a picture or a tale, which aremasterpieces, the reasons of beauty come out from thoseparticular objects. But their beauty forces everyone to recognize
it and their brightness claims a general approval.
Kant said that reflecting judgements are at work in theaesthetic field, where it is given only the particular and theuniversal is to be sought not in laws a priori of the intellect, but
in the reflection upon objects for which a preconstituted law islacking 79 . The beautiful object demands a universal recognition,
because beauty is something which tends to please universally,
but its value is to be found in the intrinsic quality of such an
object and not in relation to abstract criteria defined externally.
The successful work of art itself supplies the criteria of
judgment which should be given, since the artistic creativity has
as its own law the individual inherent rule of the piece of work.
An Italian philosopher has called “formatività” the character ofdoing which, while doing, invents the way of doing. Pure
“formatività” is the nature of art, since it is a forming just for a
forming (and not forming for any other reason or function), sothat in art the norm cannot be but the inherent norm of theindividual artistic piece of work 80 . In producing a work of art,
together with the method of application, the rule or norm whichshould be applied is also invented.
Well, we think that something like that happens also in the
moral sphere: a general ethical norm exists, but it is widely
undetermined and to be “filled”, specified and connoted throughthe specific norms that the particular situation, with its historicalcontext and characters, reveals to the interpreter. Just as theBeauty. Aesthetics and the Concept of Art, Chicago, Carus Publ. 2003
(Ital. transl. L’abuso della bellezza. da Kant alla Brillo Box, Milano,
Postmedia Books, 2008).
76
A. Caracciolo, “Bello”, Enciclopedia filosofica, Milano, Bompiani,
2006, p. 1139.
77
R. Bodei, Le forme del bello, Bologna, Il Mulino, 1995, pp. 13-14.
There have obviously been important exceptions: S. Hampshire, Logicof Appreciation (1952) in W. R. Elton, Ed., Aesthetics and Language,
Oxford, Maxwell, 1954, 161-169 (Ital. transl. Logica e fruizioni, in AA.
VV., Estetica e linguaggio, Roma, Armando, 1977, 190-198, cit. a p.
198), recommended not to follow this misleading analogy, because anartist does not need an aesthetics and when in aesthetics we pass fromthe particular to the general, we are moving in the wrong direction.
78
We use the adjective “blind” because it is true that moral judgments
are unavoidably linked to the subjective perspective of a moral agent,but it is not demostrated that this fact deletes any intersubjective validity
and leads to a complete relativism, where moral visions have noworthiness but a particular, individual, situational one. For Williams’
strategy to “defuse” this bias, see Morality (quoted above) and Ethics
and the Limits of Philosophy, Cambridge. Cambridge Univ. Press, 1985
(Ital. transl. L’etica e I limiti della filosofia, Roma-Bari, Laterza, 1987.
79
The importance of the reflecting judgements for the political andmoral thinking has been studied by E.Vollrath, Die Rekonstruktion derpolitischen Urteilskraft, Stuttgart, Klett-Cotta, 1977 and E. Pleines,
Praxis und Vernunft. Zum Begriff praktischer Urteilskraft, WürzburgAmsterdam, Königshausen Neumann-Rodopi, 1983
80
We are referring again to L. Pareyson, Estetica. Teoria dellaformatività, Milano, Sansoni, 1974.

Eubios Journal of Asian and International Bioethics 19 (March 2009)
beautiful work of art, so the good action cannot be imaged,
chosen and produced by simply applying general laws, that are
known a priori, to a rough, shapeless material. The just gesture,
like a living being, takes progressively the form, revealed andmoulded by the moral agent’s biography, desires, promises,
relationships, ideals, supreme values.
Conclusions
Camus once wrote: “You can think only through images. If
81
you want to be a philosopher, write novels” . The sense of thisprovocative sentence regards particularly the ways we do ethics
and history of ethics. We can no more think of philosophy as aself-sufficient conceptual enterprise, for the same reason thatprevents us from reconstructing the old Greek philosophy,
without considering what Aeschylus, Phidias, Euripides,
Pericles have done. Therefore the historian of philosophy has
to become historian of literature, art and religion 82 . Plato
regarded the poets as dangerous competitors, because their
tragic or epic works were reputed so morally serious and83
meaningful as a philosophical treatise .
In ethics both conceptual and emotional intelligence
cooperate in understanding and evaluating the meaning of anaction or the dignity of an existence, just like the art criticism
tries to grasp the beauty of a work of art and to show thereasons why it looks well done. The ethical discernment
intertwines logical analysis, symbolic interpretation, affective
insight, literary creativity.

Perception of Physicians andMedical Students oncommon Ethical Dilemmas ina Pakistani Medical Institute- Dr Bushra Khizar
Assistant Professor Medicine, Shifa College of Medicine
H-8/4, Islamabad, Pakistan
Email: Dr_bushrabu@hotmail.com- Dr Mobeen Iqbal
Professor of Medicine, Shifa College of Medicine
Islamabad, Pakistan
Abstract
Knowledge about medical ethics is limited in Pakistan. The
teaching of ethics in both under and postgraduate education is
generally not formal. The aim of the survey was to assess theknowledge, attitudes and practices among the medical
professionals in relation to medical ethics in an attempt toidentify the medical ethics learning needs of Pakistani doctors.
A self-administered structured questionnaire about knowledge,
attitudes and practices regarding some common bioethicalissues was devised and distributed among medical students
and doctors attending a one day medical ethics workshop heldat Shifa College of Medicine. The issues included clinicalrationing of care, abortion, medical futility, and conflict ofinterest
81

A. Camus, Carnets, Paris, Gallimard, 1962 (Ital. transl.Taccuini, v.1,
Milano, Bompiani, 1992, p. 14).
82
C. Diano, Il pensiero greco da Anassimandro agli stoici, Torino,
Bollati Boringhieri, 2007, p.68.
83
M.C.Nussbaum, The Fragility of Goodness. Luck and Ethics in Greek
Tragedy and Philosophy, Cambridge, Cambridge Univ. Press, 1986
(Ital. transl. La fragilità del bene. Fortuna ed etica nella tragedia e nella
filosofia greca, Bologna, Il Mulino, 1996, p.62).

53

A total of 110 medical personnel completed the survey.
There were 34 physicians with postgraduate diploma, 48
physicians who were either trainees or did not have any
postgraduate qualifications, and 28 medical students. There
were 56 males and 57 females. The mean age of respondents
was 32±12 years. Most doctors disagreed to deprive elderlywith expensive technologies. 91% agreed for legal abortion
where congenital defects or mother’s life is in jeopardy. There
was a strong perception for not allowing parents to discontinue
medical treatment in infants with severe physical or mental
impairment. Similar pattern of disagreement was observed inelderly with terminal disease, vegetative sate or at risk ofsevere physical or mental impairment. 95% agreed to disclose
errors during surgical procedures to the patient.
There seems to be strong element of beneficence in theperceptions of the physicians while making decisions in ethicaldilemmas.
Physicians
also
had
troubleacceptingdiscontinuation of medical treatment in infants with severe
physical or mental impairment or elderly at risk due to terminal
disease or vegetative state.
Introduction
Physicians come across ethical issues almost daily during
their routine practices. The ability to identify, understand andresolve these ethical issues is a core competency, which shouldbe part of all under and post graduate medical curricula andtraining.
Traditional medical training offers little help in resolving the
ethical dilemmas encountered by healthcare professionals due
to lack of exposure and training in this important area of
medical practice. However, on qualifying, they are expected tohave not only knowledge of medical ethics but also beequipped with necessary skills to adequately deal with them.
There have been many reports stressing the importance ofincorporating ethical and legal issues into medical curricula.
Ethics teaching needs to be strategized in a direction that it is
implemented in accordance to the needs of the particularsociety in which it would be relevant (1-3).
Teaching medical ethics as a scientific discipline is notadvisable, because it may miss the individualistic perception of
morality and ethics innate to every professional, which is a
blend of one's own unique cultural, socioeconomic andgeographical background. In order to formulate ethicalcurriculum pertinent to every region, the first step may be todetermine current basic knowledge and attitudes of thehealthcare practitioners in the region.
In Pakistan literature review shows that knowledge of
medical ethics and application is extremely poor. Even though
Pakistan Medical and Dental council code of ethics specifies
that medical ethics be taught in medical colleges in Pakistan,
unfortunately bioethics has still not found its way into formal
medical curricula.
With this background the present study is an attempt toelucidate the knowledge, attitude and practice of the physicians
and medical students in relation to health care ethics laws inPakistan.
Methods
A six item self-administered structured questionnaire wasdistributed to elicit the Physician and medical students’knowledge, beliefs and attitudes towards commonly
encountered clinical ethical scenarios, who attended a one day
Medical Ethics workshop held at Shifa College of Medicine.
The initial part of the questionnaire consisted ofdemographics such as age, gender, level of education, durationof work experience. The second part of the questionnaire
comprised questions regarding six commonly identified ethicalsituations; resource allocation, abortion, deciding the care ofseverely malformed or dying infants, end of life issues likewithdrawal or withholding treatment, disclosure of errors done
during procedures to patients and attitude of doctors to54

Eubios Journal of Asian and International Bioethics 19 (March 2009)pharmaceutical company sponsored gifts. The respondents
were asked to answer in ‘YES’ or ‘NO’ regarding all options
given against the different ethical scenarios.
The survey was distributed at one point in time to all
attendees of a lecture on clinical ethics. The data were enteredin Microsoft Excel. The results are reported in frequencies andpercentages.
Results
A total of 110 medical personnel completed the survey.
There were 34 physicians with postgraduate diploma, 28
medical students, and 48 physicians who were either trainees
or without any postgraduate qualifications. There were 56
males and 57 females. The mean age of respondents was
32±12 years.
The responses of medical students and physicians regarding
the identified, everyday ethical issues were variable (Table 1).
Table 1: Responses to the survey questions (%, (N))
Questions in the survey
YesNo
1- Allocation of Resources in 25.4%
74.5%
Elderly patient, in regards to (27)(79)
restriction of access to expensive
treatment like “Transplant
2a Abortion when strong chance of 66% (70)
34% (36)
serious defect2b mothers health is seriously 91% (96)9% (9)
threatened
2c abortion in case of a rape victim
62% (65)38% (40)
3a infant had normal brain but 26 % (28)
74% (78)
severe physical deformities
3b infant with normal brain and 9% (10)91% (96)
physical deformities which are
likely to cause death in next twentyyears
3c newborn with a normal life 10% (11)90% (95)
expectancy
butseveredisfigurement
3d infant with severe brain damage 12% (13)88% (93)
but able body only able to learn
simple tasks
3e able body but such a severe 43% (46)57% (60)
brain damage that he was never towake up
4a who might wake up from coma 21% (22)79% (83)
but had terminal illness likely tocause death in next few months
4b who might wake up from coma 21% (22)79% (83)
but left paraplegic for life again
4c may wake from coma but will 23% (24)
77% (81)learn only simple tasks like feeding
4d case who will be persistent 28% (30)
72% (76)
vegetative
4e person in deep coma unlikely to 55% (58)45% (47)
get awake
5 disclosure of errors done during 95% (101)
5% (5)
procedures to patients
Discussion
The findings of the present study clearly show the differencein the knowledge and attitudes between physicians regarding
the medical ethics and law. The respondents wererepresentative of different levels of physicians, consisting of
junior physicians inclusive of post-graduates, consultant
physicians, and medical students. Responses from both
medical practitioners and students to questions pertaining topractical ethics suggest that the majority of them were aware of
the common ethical issues.
On the question regarding restriction of allocation of
expensive treatment to elderly patient majority responded in“NO”, underlying concept governing this was probably

Beneficence to patient and influence of local religious values
with a tend towards preserving sanctity of human life. Everydecision is to be taken, keeping in view patients values andpreferences, and according to rule of justice treatment cannot
be restricted to any individual. The fact that many senior levelstaff did not feel that the patient's wishes should be asked andadhered to at all times, also reflects that decision making is
influenced by cultural and socioeconomic conditions prevailingin the area. In developing country like ours physicians tend to
adopt somewhat paternalistic attitude, as most of the populationis uneducated and poor. The patients give doctors the status
equivalent to there parents or elders and say that you are thebest person to decide whatever is in our best of interest, thephysicians have started exploiting this fact and take final
decision without discussing with patient.
In case of the possibility of obtaining legal abortion for apregnant female, responses were again variable, 91% allowed
doing abortion if the women’s own health was seriously
endangered. In case of serious defect in baby and pregnant
rape victim, there were mixed responses again showing theimpact of local cultural and religious traditions, the respondents
believe that every baby is also representative of human life, do
not allow legal abortion unless there are reasons justifying it.
In case of question pertaining to decision to forego life
sustaining treatment by the parents in consultation withpediatrician in case of different types of severely deformed
babies, most of the respondents were in favor of continuing
treatment irrespective of the given clinical scenario. The
controversies involving treatment at the beginning of life havebeen long debated. Recent controversies surrounding theproper care of imperiled newborns have emerged from theadvances of medical technologies (6). Yet the ability to save
lives places parents and physicians in a morally precarious
position, they must determine when the costs of expensive
interventions outweigh the benefits. Physicians must anticipate
the vulnerability of parents, collaborate with them, and gently
guide them through their decision. In our country it also shows
the strong influence of religion which states that life and death
is in hand of creator so in counseling the parents we have torealize the importance of religious values and let parents makeultimate decision seeking religious guidance in particular case.
On the question related to the decision to forego life
sustaining treatments in an elderly comatose patient by the
relatives, majority opted to answer in “No”. In such situations
patients own wishes are also to be taken in account before
deciding for the patient. It again shows the influence of local
traditions in our country where it’s the family or khandan, tribe
or biradari which is also closely involved in decision making, theindividuals ‘Autonomy’ is never the only principle governing
decision making.
This also happens because of high poverty prevalence incountry, health is not funded at most levels by state so thefamily is paying and they have to keep there meager resourcesin view.
In response to disclosure of errors done during procedures,almost all were in favor of it. Failing to disclose errors topatients undermines public trust in medicine because it
potentially involves deception and suggests preservation of
narrow professional interests over the well being of patients.
Disclosure of error, by contrast, is consistent with recent ethicaladvances in medicine toward more openness with patients andthe involvement of patients in their care (7).
In a developing country like ours doctors usually think that
disclosing such errors to uneducated, poor patients is not
required as they will be unable to understand completely, andwill stop trusting and coming to them in future.
In response to accepting gifts or trip from pharmaceuticalcompanies half of them were in favor of it while others wereagainst it. Campbell et al. (8), present disturbing evidence thatmany physicians accept inappropriate gifts from industry.
Physicians should not accept such gifts, because the reciprocity

Eubios Journal of Asian and International Bioethics 19 (March 2009)
they engender is known to affect prescribing decisions, which
may harm patients and increase the cost of care.
This survey shows that both the knowledge and attitudes
regarding medical ethics are variable and may be strongly
influenced by local religious, cultural and socioeconomic
factors.
Physicians deal routinely with ethical issues
Over the past few years bioethics has become an integral
part of medical education worldwide. In Pakistan at present
bioethics is not a part of curricula, both at undergraduate andpostgraduate levels except in few institutes. Pakistan as a
Muslim country with specific socioeconomic and culturalenvironment has its own requirements of medical ethics
encompassing the daily problems faced by medical
professionals that must be addressed (9).
The current situation requires a multi-pronged approachaddressing ethical teaching at all three levels of medical
education under-graduate, post-graduate and as part ofContinuous Medical Education.
It is well documented that students start facing ethicalchallenges right from the first year of medical education. It istherefore imperative that bioethics education should be
introduced from the very start. In order to be effective, ethics
education has to be seamlessly integrated into the existing
medical curriculum with clinical relevance so that it does notassume the role of just another series of lectures that have to
be endured. Ideally this integration should not only be
horizontal but also vertical throughout the five years of medical
schooling. Ethics training that not only sensitizes the students
with common ethical issues but also help’s to develop practical
judgment may be especially worthwhile for physicians (10).
Conclusions
Overall, this survey reflects the current situation ofknowledge, attitudes and practice of ethics by clinicians inPakistan where ethics is not taught as a formal subject at theundergraduate or postgraduate level (10).
This survey was done as an initial step to assess the level ofunderstanding of physicians about ethical issues being faced bythem. It was followed by series of workshops held at theinstitute for capacity building of faculty in addressing andsolving these issues.
Also this needs assessment led to planning andimplementation of undergraduate ethics curriculum at Shifa
College in form of foundation module at start of new academic
year followed by addressing relevant issues in system based
modules successfully in last two years.
References
1. Hariharan S, Jonnalagadda R, Walrond E, Moseley H : Knowledge,
attitudes and practice of healthcare ethics and law among doctors andnurses in Barbados BMC Medical Ethics 2006 , 7:7
2. Mattick K, Bligh J: Teaching and assessing medical ethics: whereare we now? J Med Ethics 2006, 32: 181 –185.
3. Eckles RE, Meslin EM, Gaffney M, Helft PR: Medical ethics
education: where are we? Where should we be going? A review. Acad
Med 2005,80:1143- 1152.
4. Cowley C. The dangers of medical ethics. J Med Ethics
2005;31:739-742
5. Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI.
Understanding the clinical dilemmas that shape medical students’ethical development: questionnaire survey and focus group study.
BMJ 2001;322:709-710.
6. Siingh J, Lantos J, Meadow W, End -of -Life After Birth: Death andDying in Neonatal Intensive Care Unit .Peadiatrics 2004,114:16201626.
7. Gallagher H T, Waterman D A, Ebers G A, Fraser J V, Levinson W,
Patients’ and Physicians’ Attitudes Regarding the Disclosure of
Medical Errors 2003; 289: 1001-1007.
8. Campbell G E, Gruen L R, Mountford J, Miller .G L, Cleary DP,
Bluementhal D, A National Survey of Physician-Industry Relationships
2007;356: 1742-1750.

55

9. Shirazi B, Shamim S M, Shahmim S M, Ahmed A, Medical ethics insurgical wards: knowledge, attitude and practice of surgical teammembers in Karachi Indian J Med Ethics. 2005;2(3):94-96.
10. Jafarey A M, Bioethics and Medical Education, JPMA: 2003

Altruism: An EthicalResource for Dealing withHIV and AIDS
- Helen Kunbi Labeodan, PhD
Department of Religious Studies, University of Ibadan, Nigeria
Email: kunbial@yahoo.com
As we enter the third decade of the HIV and AIDS epidemic,
effective and creative strategies to combat the disease and deal
with the challenges posed by it are more critical than ever. The
issue of HIV and AIDS invites us to reflect on human relations
at communal and global levels. Globalization increases thisproblem by promoting a consumer mentality whereby sexuality
is reduced to a commodity.
According to Sam Kobia (WCC Study Document, 2001: vii)
in promoting prevention measures it is imperative to have thewider picture – to restore to sexuality its integrity. If sexuality istreated as a commodity, the technical advice that would begiven to stop the spread of Sexually Transmitted Diseases(STDS) is to increase the use of condoms. It should be notedthat the moral admonition to remain faithful has its limitations
because its emphasis is more on the individual than on thecommunity. A sufficient and effective control of HIV and AIDS
will depend more on the quality of human relations and of ourinstitutions.
Benezet Bujo, (2001: vii) argued: “Although the problem of
AIDS is too often linked to sexuality alone, it must be put
forward explicitly that our materialistic desires also let many
people fall victims of this disease”.
To a very large extent public health action is a function ofpolitical considerations, which take place in the context ofcontested meanings and unequal power (2001: vix). When it
comes to resource allocation the rural areas usually get a raw
deal. The urban elite who dominates political power considered
HIV and AIDS as an “urban disease” and for a long time healthbudgetary allocations were tilted in favour of the urban areas.
The health work was also concentrated in the urban centres. It
was a long time before the key players recognized AIDS as adevelopment issue (2001: ix).
The newly formed Ecumenical Advocacy Alliance (EAA)
acknowledges the HIV and AIDS pandemic to be “one of thegreatest health challenges facing the world at the moment. It isalso, arguably, the gravest challenge to prospects of social andeconomic development and global security”. The question now
is: “How do we stop the spread of this deadly disease?” Before
we can answer this question, let us briefly examine practices
that put people at risk.
Practices that put People at Risk
Communities continue to embrace cultural practices that put
people at risk of contacting the HIV and AIDS. Since cultural
practices do not give room for open discussion of sexuality,
people might never be educated on issues related to theirsexuality. It is therefore importance for there to be sex
education, which will help in dealing with HIV and AIDS. The
sex education is for both sexes: without involving both parties
the problem will not get solved. According to UNIFEM, theculture of silence that surrounds female sexuality in manysocieties prevents women and girls from accessing informationand services for protection or treatment.
There are, however, other cultural practices that aid the

56

Eubios Journal of Asian and International Bioethics 19 (March 2009)

spread of HIV and AIDS. A few of these factors include:
Female Circumcision
The instruments used for circumcision are most times notsterilized. This lead to multiple infections the reason been that,the same instruments are used for many people.
Widowhood InheritanceIn a situation where a widow is inherited by one of her
husband’s relatives, the widow, who may already have thevirus, is likely to transmit it to the unsuspecting partner who willthen transfer it to his own wife. And it may be vice-versa.
Polygamy
The practice of marrying several wives is also a major
problem. If either the husband or one of the wives should get
infected, there is a high risk of others in this marriage to
become infected as well.
Prostitution
There are numerous reasons why women go into prostitution
but most times the reason given is poverty. As a result of this,they are not in a position to demand safe and responsible
sexual practices, which include the use of condoms.
Violence
According to UNIFEM reports, gender-based violence, both
inside and outside the household, increases women’svulnerability to HIV and AIDS. This vulnerability increases
because of a mistaken belief that sex with a virgin can cure
AIDS.
AIDS is transmitted in several ways including: sexualintercourse; transfusion of unscreened blood; the use of
unsterilised syringes, needles, blades, knives, shaving sticks
and other sharp objects; or any other act that allows thetransmission from one person to another like drinking anotherperson’s blood, direct contact with another person’s blood orbody fluid. It can also be transmitted by trans placental infection(vertical transmission of HIV). An HIV infected pregnant woman
can pass the virus to the foetus in her womb.
There are some variables affecting the mode of transmission
and the rate of progression of the HIV, and multiple sexual
partners is a great risk factor in the spread of HIV and AIDS.
This habit leads to the formation of a sexual network, which is
the real environment for the rapid spread of the disease inmany places.
Challenges Faced by People Living with HIV and AIDS
People living with HIV and AIDS usually face discrimination,
stigmatization and denial. It has become important for PLWHA
to risk stigmatization, discrimination and denial by breaking thesilence around HIV and AIDS.
In many places, people are still reluctant to acknowledge therelevance of HIV and AIDS to their own lives because of theshame and fear that surround this fatal disease and thediscrimination and stigmatization directed at those affected.
People having or suspected of having HIV infection may beturned away by health care providers, denied jobs and housing,refused insurance and entry to foreign countries. Their spouses
or families may throw them out. They may even be murdered.
Surprisingly, they are also thrown out of their churches, a place
where they expect to find solace and comfort.
It is for these reasons that individuals who suspect or knowthat they are infected do not wish to disclose their status
publicly. Some infected persons even shy away from telling
their spouses or partners. This attitude of keeping silencehinders both prevention and care and these people will lose
precious opportunities for warding off or treating illnesses
brought on by the infection.
The stigma surrounding AIDS can extend into the next
generation, placing a further emotional burden on the shouldersof orphans and other survivors (Daini, 2002: 49). When children

whose parents had died of AIDS in the hard-hit rural communityof Rusinga Island, Kenya, were asked about the cause of theirparents’ death most of them said that their parents died of acurse. None mentioned AIDS (Daini, 2002: 49). We have similar
stories in other counties of Africa, for instance Nigeria. The
reason why stories of this type are told is the fear of being
stigmatized as children of AIDS victims, for this may cost thema lot within their society or community. They may be isolated
out of a fear that they, too, may be carriers. Most importantly
when these children are of marriageable age, no one will wantto marry children of AIDS victims. It is for this reason that wehave stories of witchcraft attack and curses.
HIV and AIDS is a severely stigmatizing illness. It is not a“glamorous” disease nor is it one that excites public sympathy
like cancer and hepatitis. News of HIV and AIDS is usually
received in lay circles with fear and avoidance. AIDS still carries
a stigma like that experienced by lepers in most African
societies today (Daini, 2002: 78). This has, however, changed
over the year through love and sympathy for those affected.
Today, a diagnosis of HIV and AIDS is like issuing a deathcertificate to a person. Society sees the person as an outcast, adirty, morally inferior, and most times as being promiscuous,and besides having a relationship with a person living with HIV
and AIDS is a ‘death trap’. Society withdraws from PLWHA and
PLWHA themselves withdraw from the society. Some
employers terminate the employment of such persons andlandlords sometimes evict them from their houses. There is alsosocial isolation of PLWHA by friends, associates, lovers andsometimes relations.
Many people living with HIV and AIDS deny and reject theveracity of the diagnosis of AIDS by qualified medical
authorities saying: “I don’t have it…” They seek sympathy inorder to avoid the presumption of involvement in promiscuity
saying: “I have a terminal cancer”, or “I have tuberculosis”.
Sometimes they decide to be superstitious, attributing theirconditions to supernatural forces. All these are just attempts by
the positive person to avoid the social scorn and rejection thatis commonly associated with the disease. Unfortunately, people
who deny the veracity of their HIV positive condition and thecause of it sometimes continue in various activities that may
encourage the spread of the disease. The issue now is how we
can put an end to these challenges faced by PLWHA before it
gets out of hand. This paper has put forward altruism, aphilosophical concept that is also ethical in nature.
The Concept of Altruism
Auguste Comte used the term altruism in 1851 from the
Italian adjective altrui. He employed the term to denote thebenevolent propensities as contrasted with the selfish
propensities (Kelvin Knights, 2002: 1). It is used in a
psychological sense to designate emotion of a reflective kind,
the immediate consequences of which are beneficial to others.
Its significance is ethical. As such it defines a theory of conduct
having for their object the happiness of others.
Comte’s system is both ethical and religious. Not only ishappiness to be found in living for others as the supreme end of
conduct, but also a devotion to humanity as a whole is thehighest form of religious service.
Altruism denotes pure concern for others. It is an action
designated to benefit others rather than the doer. It is a highly
revered human activity that is eulogized by religious apologists,social reformers and revolutionist movements. Christiandiscipleship involves self-sacrifice and attention to the interestof others: “Do unto others as you would have them to do untoyou” (Aina, 2001: 21).
It is better to be an altruist than to be an egoist. Egoism
means a regard for one’s private good at the expense of other’sinterests. It depicts the solitary state of existence. It is also a
principle that supports the view that what suits me always
justifies my conduct, since no one else is sufficiently like me.
An egoist does what he thinks will give him the greatest
balance of good over evil. Human beings are naturally egoist,

Eubios Journal of Asian and International Bioethics 19 (March 2009)
for according to Thomas Hobbes, all voluntary acts of men tend
to the benefit of themselves and all voluntary acts, the object isto every man his own good (Barcalow, 1992: 84).
It has, however, become imperative for human beings to be
altruistic in their attitudes toward life for the sake of others. As
human beings we have to be benevolent. According to A.C.
Ewing, benevolence is just as natural as self-love. Self-love is
not the only self-instinct. It is wrong to hurt ourselves, as it iswrong to hurt others. Hence the need for altruism which is thepure concern for others.
Applying Altruism to HIV and AIDS
Going by the definition and explanation given on altruism
above, it is not only people around those living with HIV and
AIDS who have to be altruistic in their attitude; those living withHIV and AIDS too must be altruistic in their attitudes toward
others. How is this to be done? Persons living with HIV and
AIDS must be ready and willing to let people know their status.
We are aware of the fact that in letting people know of theirstatus, they are open to all forms of discrimination andstigmatization by those around and even by those from whomthey think they will find support. But then, this is a chance theymust be willing to take and a price they have to pay for being
infected, even though it may not be their fault.
Since altruism means showing concern for others, PLWHA
must let those around them know their status so that existing
relationships can be redefined. For instance, in a situation
where a man tests positive, he must let his wife know andencourage her to go for a test and in a situation where she is
not infected, he must be willing to use condom when they wantto have sex so as not to get her infected.
One of the questions that readily come to the mind of
PLWHA is, “Will I be welcomed in my family, among my friends
and in my local church?” This is, indeed, a question that will test
the integrity and credibility of all people who bear Christ’s name.
The question also challenges the church to live in loving
acceptance of all persons whose lives have been touched by
AIDS.
Those around PLWHA must also be altruistic in theirattitudes to those living with HIV and AIDS. They must let theirfaith reflect in their attitude towards them. They must ask
themselves, “What would Jesus Christ have done in thissituation? Would He send them away, discriminate againstthem and stigmatize them and deny them the much needed
love and support”? Jesus Christ would not have done these.
Rather, He would have shown them great love andcompassion.
Since, as Christians, we are followers of Jesus Christ, wemust be ready to do as He did. Jesus Christ was altruistic in His
attitude towards human beings. He was not thinking of Himself
when He gave Himself up on the cross of Calvary for thesalvation of mankind. What was on His mind was what could bedone so that humanity could be delivered from Satan. He knewthat the only way Satan could be defeated was by giving
Himself up. Likewise, in the face of the HIV and AIDS pandemic
now plaguing the whole world, the only way by which we can
defeat this deadly disease is by being altruistic in our attitude.
It has therefore become necessary that those around
PLWHA must ask for God’s guidance that they may respond inways that bear witness always to Jesus’ own compassionate
ministry of healing and reconciliation, and that to this end we
may love one another and care for one another with the same
unmeasured and unconditional love that Jesus embodied (The
United Methodist Church’s Resolution on “AIDS and the
Healing Ministry of the Church” The Book of Resolution, 1992).
People around PLWHA can be altruistic in their attitudes bydestigmatizing the disease through education and care andsupport programmes. They can also demystify the scourge
through healthy and social interaction with PLWHA. They
should help PLWHA accept their condition and encourage themthat it is possible to continue to live a normal life.

57

PLWHA should come together to form a formidable force,
relate well with one another and try as much as possible to help
the society in preventing the spread of the disease. They
should get education on the disease, how they can continue tolive a healthy and normal life and they should also educate
those around them – like their lovers, their spouses, theirchildren, their families and their friends.
We all know that people are not angels and that they tend tolook after themselves and their own first. Yet we know thatcooperation does occur and that our civilization is based upon it(Axelrod, 1994: 88). A cooperative attitude brings about
altruistic attitudes. You look out for others and other people dothe same for you.
It is important to point out here that if the highest level ofunderstanding and cooperation is not used to solve theproblem, no member of the society can claim total freedom fromrisk of infection, considering its modes of transmission and its
ubiquity (Daini, 2002: 80).
The Church and Altruism
From the beginning of the pandemic some churches havebeen altruistic in their attitudes to those living with HIV and
AIDS. These churches and church-related institutions havebeen active in education and prevention programmes and in
caring for people living with HIV and AIDS. However, theresponses of the churches have been inadequate and have, insome cases, even made the problem worse (WCC Study
Document, p. 5). As the WCC executive committee noted in
1987, “through their silence many churches share responsibility
for the fear that has swept our world more quickly than the virus
itself”.
Altruistic Attitude of the Churches
Christian love is another word for altruism. Showing lovemeans you are concerned about others. In the face of HIV and
AIDS, some churches have shown true Christian love by caring
for, supporting and praying for those living with HIV and AIDS.
Here is the story of Peter Braswell, a caregiver.
Peter Braswell loved one Tim who was living with HIV and
AIDS. After a while they both needed the kind of support only achurch could give. Peter knew that he had to tell his Pastor
about Tim. Peter said,“My faith in the church and my ministers had never been put
through a test before, and certainly not with anything asfrightening and controversial as AIDS. How were they going to
respond? I wanted my pastor to respond with love andcompassion and even I had an angry response ready just incase he did not respond, as I want. My fears and anger werequickly dispelled by his warmth and compassion, along with his
promise to do everything in his power to help Tim. Later, I found
not that he was not only there for Tim, but he was there for me
as well”.
What has happened here is the true meaning of Christian
love. Not only was Peter’s faith nurtured; his friend Tim got the
support of his church and his pastors (Braswell, 1989).
Peter’s experience reminds us that there are people livingwith AIDS and their loved ones are reaching out and waiting forthe church and the community of faith to respond being
altruistic and adhering to Jesus’ injunction to love our neighbour
as our self.
The experience of the Corys was, however, different fromthat of Tim. Catherine Cory received a massive transfusion ofblood after experiencing post-operative bleeding after giving
birth to their son, Alex. This was in February 1986. In the springof 1987, she tested positive for HIV and subsequent testing of
the rest of the family showed that Alex was positive andRichard (father and husband) was not.
Catherine had got infected through the fault of the hospital,
which did not screen the blood before transfusing, and Alex got
infected through breast-feeding. The Cory family met with lack58

Eubios Journal of Asian and International Bioethics 19 (March 2009)of love and support from everyone around them, even fromtheir church.
HIV and AIDS is a pressing issue that needs an immediate
solution. People must be encouraged to make altruism a reality
in the society by showing concern for those around them. Being
altruistic is a mindset that must be adopted by every member ofthe society. People living with HIV and AIDS are human andthey have a need to be needed. Treating those with HIV and
AIDS with kindness and dignity is by far the greatest gift thatcan be given. The “golden rule” applies: “Do unto others as you
would have them do unto you”.
References
A WCC Study Document (2001). Facing AIDS – The Challenges, theChurches’ Response (WCC Publications, Geneva), p. viii.
Aina, A. (2001). “Egoism and Altruism as Moral Theories” in Oduwole
and Olaolu (eds), Fundamental Theories and Issues in Ethics (Ben-elBooks, Nigeria).
Daini, W. (2002), HIV/AIDS: Restoring Hope and Life (A Frankad
Publication, Nigeria).
Jonathan Mernin and Reuben Granich (2001). HIV, Health and yourCommunity – A Guide for Action (The Hesperian Foundation,
Berkeley, California, USA).
Kevin Knight (2003). “Altruism” in the Catholic Encyclopedia, Vol. 1,
Online edition.
Peter Braswell (1989), “This is the Day” – http://www.unaids.org / oraidsmin@gbgm-umc.org.
Richard Cory (1989). “Do Unto Others” – http://www.unaids.org.

Evolution of altruism- K. K. Verma, Ph.D.,
Retd. Professor of Zoology, HIG 1/327,
Housing Board Colony, Borsi, Durg – 491001, India.
Email: kk.sheel@gmail.com- Suresh C. Sharma, M.A. (Eng.), M.A. (Psychology),
Retd. Professor of English, ‘Jagdish-Satya’55, Mohan Nagar, Durg – 491001, India.
Email: 108@rediffmail.com
It has been shown through several examples from among
insects and mammals that altruism has evolved as a corollary
to group living, and that it is maximally developed in eusocial
species, specially among humans due to their compact andintricate social pattern of life (Saxena and Verma, 2007). It has
also been inferred that humans have genetic proclivity both for
altruism as well as for violence (Verma, 2008). Evolution of boththe proclivities has been deduced from group behaviour among
chimpanzees and from comparable phenomenon among
primitive human tribes. Verma and Saxena (2000) have pointed
out, “Human nationalism and patriotism have their origin in the
territorial instinct”, which is so common among animals.
In this context a small but a very significant paper by Bowles(2008) has been published, and it is of special interest. The
author has developed the thesis that altruism and parochialism
act synergistically mutually. Altruism is subjugation of self forgood of others. As per Bowles (loc. cit.) “parochialism isfavouring ethnic, racial or other insiders over outsiders”.
Genetic proclivity for violence and parochialism find theirmaximally pronounced expression in wars. As Bowles haspointed out, wars have been taking place since prehistoric
times, as has been inferred from examination of a large numberof prehistoric burials of men and women with broken skulls andforearms and pointed stone pieces embedded in the bone.
War-like group conflicts are known among chimps and fire
ants, but among humans such conflicts are often on muchlarger scales. A group of humans, suffering from scanty naturaland reproductive resources, may attack a neighbouring group
to augment its resources, and a war-like situation results. Under
these circumstances both altruism and parochialism show an
upward trend in either group; this is what is referred to as

mutual synergistic effect between altruism and parochialism. In
a war altruistic attitude is maximally developed among‘insiders’, and also parochialism takes an exaggerated form of
hatred and animosity towards ‘outsiders’.
But among tribals there are also instances of sympathetic
and friendly relations among neighbouring tribes. Tribes invicinity may exchange gifts, and may offer help to neighbours inadverse conditions.
Development of projectile weapons, killing enemy from a
distance, has reduced the immediate personal cost of
aggression, and has made lethal conflicts more lethal anddestructive (Bowles loc. cit.). Continued development of such
weapons has led to long shooting range guns, missiles andeven nuclear warheads. The enormous destructions, caused bysuch advanced weapons has led to peaceful coordination
among states, as evidenced by formation of United Nations andthe European Union as an aftermath of the Second World War.
Natural calamities have also promoted interstate altruism.
There are numerous instances of developed countries
extending help to less developed nations in the event of famineor calamities like earthquakes and floods.
Bowles points out that the synergistic relations between
altruism and parochialism could be repeatedly verified byseveral workers through computer simulations. In such
simulations groups were made with both altruists and parochialaltruists (i.e. with both attributes of altruism for ‘insiders’ andparochialism for ‘outsiders’) in different proportions. On creating
war-like situations between two such groups, the group withhigher proportion of parochial-altruists was found to be thewinner in such conflicts. When populations, resulting fromthousands of generations of selection, were examined, some
populations had become tolerant and selfish, with little warring
tendency, while others were parochial and altruistic withfrequent and lethal encounters with other groups. Sometransitional groups between the two types were also obtained.
What is important to note is, “neither altruism nor parochialism
ever proliferate singly; they share common fate, with war theelixir of their success” (Bowles loc.cit.).
‘Ingroup’ altruism is enhanced not only by increase in‘outgroup’ parochialism but also by the fine distribution of labour
in a human society. As a result of such a distribution individuals
in one trade have to depend for the ‘fruits’ of another trade on
the specialists of the latter trade. Through their mathematicalmodels Fletcher and Doebeli (2009) have come to a similarinference, that ‘give-and-take’ promotes mutual dependence
and altruism. These authors say, “an altruistic genotype
requires that carriers of the genotype are overcompensated fortheir altruistic sacrifice by benefits received from others”.
Fletcher and Doebeli (loc. cit.) point out that ‘population
viscosity’, i.e. limited dispersal, also promotes altruism. Wilson
and Wilson (2007) have formulated a hypothesis about
evolution among humans. They say that evolutionary changes
in humans are multilayered. Such changes occur both at theindividual level as well as at the group level. The hypothesis
further says that in a group or a society there are someindividualist members and some altruistic ones. An individualist
considers only his individual gains and not the social needs. He
may take even to tortuous ways for personal benefit and ignore
the social ethics. He may well provide his family and afford
costly education for his children, who will inherit the traits fromtheir parents, and theirs will be a prosperous family. Thus thisfamily will be positively selected at the family level, but willcontribute little to or even harm the social structure. An altruist
will concentrate on social needs, will keep in view the laws of
the land and the religious ethics, but may do not much for his
family. In this family there will be, in comparative terms, anegative selection at the family level, but at the group or social
level evolution theirs will be a positive contribution andselection. Thus both individualists and altruists have to face a“trade off”. If in a society altruists dominate, this society will dobetter and will be more progressive than another society, inwhich individualists have dominance. A society with the latterEubios Journal of Asian and International Bioethics 19 (March 2009)
constitution may suffer from internal conflicts and eventual
breakup.
In the preceding paragraph, inheritance by children in thefamily has been mentioned. It may be kept in view that among
humans inheritance is not only genetic but also cultural,
because of a long post-natal association with parents and therest of the family, and an extra long period of psychologicalimmaturity.
The hypothesis by Wilson and Wilson (loc. cit.) has been
well supported by several computer generated models
considering all the relevant factors.
One of the inferences, reached from the recent studies,
discussed above, is that increasing altruism within a group isassociated with increasing parochialism against another group.
But for growth of civilization the highly destructive and lethal
wars have to be avoided, while interstate and intergroup
altruism is desired. Can we counter the natural tendency ofaltruism and parochialism increasing hand-in-hand throughcultural processes, like education and religion? It is an
important question awaiting an answer. If an answer,
suggesting a feasible plan of action, could be found, it will help
practicing a basic precept of Hinduism, “vasudhev
kutumbakam”, i.e. all the world one family.
References
Bowles, S., 2008. Conflict: altrusim’s midwife. Nature, 456 (November2008):326 – 327.
Fletcher, J.A., and Doebeli, M., 2009. A simple and general explanation
for the evolution of altruism. Proceedings of the Royal Society B, 276:
13 – 19.
(doi: 10.1098/rspb.2008.0829)
Saxena, R., and Verma, K.K., 2007. Morality – innate or acquired?.
EJAIB, 17(1):11 – 14.
Verma, K.K., 2008. violence and war. EJAIB, 18(3): 70 – 71.
Verma, K.K., and Saxena, R., 2000. Man in Biological Perspective.
Himanshu Publications, Udaipur/New Delhi.
Wilson, D.S., and Wilson, E.O., 2007. Rethinking the theoreticalfoundation of Sociobiology. The Quarterly Review of Biology, 82(4):327 – 348.

The rare plants' lamentation- Bing H. Tang, M P H, M D
Research
Consultant,
New
York
CollegeofTraditional Chinese Medicine
Address: Research and Ethics, 182 - 01 Union Tpke, Fresh
Meadow, N Y, 11366, USA
Email: prof.bing@gmail.com
We are Rare plants;
you may want
To tell us that since we know
We are rare, we likely have no
Value in your market.
Well, weAlso know that weHave'n created by the Creator
Just like you have'n - no more than you,
No less than you either
Of course,
You can find us as
Carnivorous Plants ofAustralia; also, learn us
In the U S as imperiled plants.
Rare plants
From the watershed;
The rarity is decided

59

On the humans' listing for us:
How do they view about us.
For examples, Just to name a few:
The plant such as curly grass fern,
Is the one circuitous.
There are, too, others.
Swamp pink,
Bog asphodel,
Slender nutrush, sedge livid,
Pine barren smoke grass, sand myrtle
And bladderwort purple.
Neither,
We're complaining all;Never have we claimed about
All of the human's vigilance
Nevertheless, as to
We live
Up to the human;Some of their turmoil
Helps: recreation carriage,
And digging ponds and dykes.
Besides,
Many sand roads,
The widespread sand residue,
Furthermore, power-line clearance
And the huge borrow pit.
Humans' all
Other turbulences
Yet are detrimental:
Such as excessive landscaping,Residential and industrial
development corrupting.
We areNow sobbing and trying
To survive between ourContinued subsistence and theirOwn excessive desire.
Is there no way for them to weigh?
For humans, they must appraise;
The human should bring all to light.
References
Lowrie A. Carnivorous Plants of Australia, vol. 3
A Lowrie - 1999 - University of Western Australia Press: Perth
National Collection of Imperiled Plants Jan 29, 2008
Schuyler AE, Gordon T (2002) Rare plants in the Middle Branch of theForked River watershed, Lacey Township, Ocean County, New
Jersey. Bartonia, 117-121. ...
www.newcrops.uq.edu.au/listing
Tang B. The adverse effect in vivo from OZONE LAYER DEPLETION,
along with Reflections in Environmental Ethics. Spring 2007 IN VIVO,
the publication of the Metropolitan Association of College andUniversity Biologists, N Y, US,
2007;28(3): 25-30
Tang B, Spring , 2008 In Vitro maturation of N K cells in the humanumblical cord blood treated with wheat grass extract: A pilot study. In
Vivo, Vol. 29 (3) 9-20
Tang B, Fall, 2007 The Effect of Grape Seed Extract on hematopoietic
Stem cells in the Umbilical Cord Blood. in Vivo, Vol. 29 (1)10-15
Tang B, Winter, 2007 DNA damage of plants due to depletion ofstratospheric ozone, and acid rain: the mechanism of Photorepairing
for the damage. (IN VIVO, The publication of the Metropolitan
Association of College and University Biologists, N Y, US, Winter,
2007, Vol. 28, Issue 2, p. 4-9

60

Eubios Journal of Asian and International Bioethics 19 (March 2009)

Tang B. The adverse effect in vivo from OZONE LAYER DEPLETION,
along with Reflections in Environmental Ethics. Spring 2007 IN VIVO,
the publication of the Metropolitan Association of College andUniversity Biologists, N Y, US,
2007;28(3): 25-30
www.centerforplantconservation.org/ASP/CPC_ViewProfile.asp?CPCN
um=4460 - 43k

Arts Bioethics Network (ABN)
Yatho hasta thatho dristi
Yatho Drishti thatho manaha
Yatho manaha thatho baavou
Yatho bhavou thatho rasaha
Where the hand goes, the eyes follow,
And where the eyes are, is the mind,
And where the mind focuses, it is reflected in the expressions(facial and otherwise)
And when the mind focuses, the dancer and the audienceengage.
‐Natyashastra (A classical Indian text on dance)

With such a structured approach to dance, Bharathanatyam
is capable of capturing complex and difficult ideas andengaging the audience at an intellectual and emotional level.
Savithri, a solo Bharathanatyam dance composition on deathand life extension, inspired by Sri Aurobindo’s epic work of thethsame name was presented at the 9 World Congress of
Bioethics at Croatia, in an attempt to encapsulate Hindu ideas
on death and the nature of life and the ethics of the quest forlife extension. As art is often the keeper of knowledge andethics in many communities the pursuit for inclusiveness ininternational bioethics debate would be well served by taking
account of artistic explorations. By showcasing Savithri andother works the Arts Bioethics Network endeavours to bringdiversity to the international discussion of bioethics.
The aim of the Arts Bioethics Network (ABN) is to bringartists and non-artists together and to introduce arts as acomponent in interdisciplinary research and knowledge
building. In order to facilitate creative approaches to bioethics,
ABN organised two major events – an arts exhibition and athperformance session at the 9 World Congress of Bioethics.
Other papers at the Congress which incorporated arts into
bioethics and education explored eastern ethics via yoga,
explored the use of pelvic dance movements to increase healthawareness about low back pain, the use of speculative social
narrative and design proposals to generate an alternative wayof debating about social, cultural and ethical issues surrounding
life sciences, and the use of DVD for teaching philosophy,
ethics, law and linguistic analyses. The highlight of the evening
sessions at the congress was the screening of the movie
Romulus, My Father. This was followed by an active discussionthat arose from topics covered in the movie.
The arts exhibition entitled The Art of Bioethics was wellreceived. In his opening remarks for the exhibition, Professor
Raimond Gaita, a philosopher and bioethicist from Australia,
commented that the exhibits prompted the viewer tomeditatively reflect on bioethical issues, rather than deliberate
on bioethical issues. He was of the view that bioethicists should
not just engage in analysis of what the principles of conduct
should be and how to rationally justify them, but to reflect on
moral thought in the context of the human condition. Among theexhibits were The Lake which raised the question of whether
humans should manipulate other life just because it is possible
for them to do so, Closed Reality Embryo - an interactive exhibit
allowed two participants to jointly create an embryo, whileallowing them to choose genetic characteristics of the baby.
Balance of Power, Drugs for Healthy People and Promotional
Mugs alluded to the power relationships existing between

doctors, patients and pharmaceutical companies. The Smile ofa Stem Cell was a collection of photographs produced byscientists based on their laboratory work on stem cells. Finally
Quantum Gene was an amalgamation of ideas from quantum
physics and the genome sequence.
The performance session, chaired by Dr. Paul Ulhas
MacNeill along with Dr. Chamu Kuppuswamy saw theparticipation of both in performances. Dr. Macneill played a rolein The Carousel Ride – a drama on organ transplantation andthe moral issues surrounding payment for organs. Dr.
Kuppuswamy
presented
theBharathanatyam
dance
performance. Two documentaries on care of the elderly andwomen’s reproductive choices highlighted the power of themedium of documentary well. The Icarus Project was a tale
combining modern and mythical narrative to educate and informteenagers about stem cell research. Poetry also featured in thesession and was presented in French preceded by a shortcommentary on its poetic features and content.
The co-ordinators intend, through their efforts to expand thework of ABN, to deepen and extend the role of the arts inbioethics by fostering joint thinking amongst scholars fromdifferent disciplines. One such effort is taking shape as aproject proposal to promote health awareness amongst womenin Taiwan through use of pelvic dance movements developed
from ancient cave paintings in Dunhuang.
Artistic collaborations have great potential in involving the
public, the academics and policy makers in a joint engagement
on bioethics. At the very least ABN events added an additional
dimension to ethical debate at the congress. Perhaps, andmore ambitiously, it has inspired participants and viewers topush the boundaries of interdisciplinary knowledge production
into unprecedented territories.
ABN Contributors: Bailey Barash (203 Days), Gus Clutterbuck(Balance of Power, Drugs for Healthy People and PromotionalMugs), Katherine Koller, Angela Thachuk, Florencia Luna, PaulUlhas Macneill, Bailey Barash (The Carousel Ride), Chamu
Kuppuswamy (Quantum Gene, Savithri), Andreja Kulunčić(Closed Embryo Reality), Peter Rumney and Nettie Scriven(The Icarus Project) Julie Freeman (The Lake), Sebastien
Duprat (Smile of a Stem Cell, La vie, Ma vie : c’est quoi ? c’est
quand ?), Debora Diniz (Severina’s Story), Serene Chi, Elio
Caccavale, Paul Ulhas Macneill (arts papers)
For more information contact the coordinators of the network:
Dr Chamu Kuppuswamy (c.kuppuswamy@shef.ac.uk) and
Dr. Paul Ulhas Macneill (pmacneill@med.usyd.edu.au)Eubios Journal of Asian and International Bioethics 19 (March 2009)

Human Cloning: Prospects
and Challenges in the AsiaPacific Region- Shamima Parvin Lasker
Professor of Anatomy
City Dental College
Dhaka , Bangladesh.
Email: splasker04@yahoo.com
Abstract
Cloning research has been said to be one of the world’s ten
great technologies achieved in 2000. A number of Asian
countries are pioneers in human cloning research. The sourceof the material for cloning research has raised ethicalquestions. Although most of the counties in Asia and the Pacifichave passed laws prohibiting the implantation of cloned humanembryos for reproductive purposes, embryonic stem (ES) cellresearch has drawn special attention for undertaking
revolutionary treatment of disease, in China, Japan, Singapore,
Thailand and Malaysia. Regulations concerning stem cellresearch differ from nation to nation in Asia-Pacific region.
Guidelines regarding the reproductive and therapeutic cloning
are discussed. Freedom of research and discovery for the
benefit of humankind must be respected but unethical scientificadventurism also needs to be checked. Biotechnologicalstadvancement in 21 century in this line may challenge us torethink and redraw the moral boundaries of the United Nations
Declaration on Human Cloning.
Introduction
Cloning research is one of the world’s ten greatest
technologies achieved in 2000. By modern biomedical
technology, it is possible to produce every tissue from embryo
stem (ES) cells to repair and replace the pathological or
decrepit tissue and organ of human. Thus scientists hope totreat cancer, diabetes, nervous tissue disease, heart disease,immunity disease and genetic disease as well. Alhoughimmunological rejection is still not resolved, cloning humanembryos and stem cells for auto transplantation could eliminate
immunological rejection. Therefore scientists are pursuingexperiments to reduce the human suffering and expand the lifeof human. But the source of the material and purpose of
research has raised scientific, medical, moral, ethical and legal
questions.
Definition of Cloning
A group of organisms with an identical genetic make-up arederived from a single individual as a result of non-sextual
reproduction is called cloning. It should not be forgotten that
this sort of cloning exists in nature, particularly in certain plant
species, several invertebrates and lower organisms. Genetically
identical monogygotic twins in humans are the result of anatural form of cloning.
Embryonic Stem (ES) cells are early original cells with highmultiplication as well as unilateral and multilateral polarization
potential. There are totipotent, pluripotent and monopotent stem
cells. Totipotent stem cells could polarize into 200 types ofhuman cell constituting every tissue, organ and finally grow into
a whole body. Pluripotent cells are derived from totipotent cells
and have potential to form many sort of cells. Monopotent stem
cells are formed from pluripotent cells and can only give rise
one or two closely interrelated type of cells such as stem cells
for epithelial or muscle cells.
Source of stem cells:
1.
Embryonic tissue from abortions

61

2.
In vitro fertilization (IVF) to make embryos fromdonated gametes
3.
Use of surplus embryos from IVF
4.
Cloningembryosbysomatic
cell
nucleartransplantation technology via asexual reproduction.
Human Cloning in Asia-Pacific
A number of Asian countries are pioneers in human cloning
research. Lee Boyon, Professor of an Infertility clinic at
Kyonghee University succeeded in cloning a human embryousing nuclear transfer technology in 1988. This is the 1streported case of cloning of a human embryo.
In the beginning of the 21st century, Chen Xigu, professor ofexperimental animal centre of Sun Yat–sen University,transferred a skin cell nucleus from a 7 year old boy into arabbits denucleated egg and created a embryo aiming to use
cloning to cure diabetes and Parkinson’s disease. Next year, in
2002, Li Lingsong, at Peking University announced that he hascloned a glandular structure that secrets chemicals helpful intreating diabetes and Parkinson’s disease. He is trying to put
human cells into animal embryos to produce human organs foruse in organ transplantation. One research group acquired
embryonic brain tissue from 6 to 8 months gestation aborted
fetuses/miscarriages. The Medical Science Institution of
Shiijazhuang city of China and Henna Medical University did
intracranial transplant with human embryo stem cell andreported good curative effect in brain agenesis.
A Japanese scientist put tretinoin into thousands of frog stem
cells and produced frog eyes and ears. Another Japanese
university scientist transplanted the experimental rat heart into
ventral aorta and cultivated a new rat’s heart. In 2000, Hwang
Woo-Suk, Veterinary Medicine at Seoul National University
succeeded in cloning a cow named Yongrongi for mad cow
disease research. Singapore is a leading manufacturer ofembryonic stem cells world wide.
Laws on Cloning and Stem Cell Research in Some AsianCountries
Regulations regarding reproductive and therapeutic cloning
differed from nation to nation in Asia-Pacific region. All types ofcloning are illegal in some countries like Hong Kong, Philippines
and Bangladesh. But most counties, except Iran in the Asia andthe Pacific, have passed laws that prohibit the implantation ofcloned human embryos for reproductive purpose only allowing
ES cell research.
In China any research for human reproductive cloning shallbe prohibited. Experiments in vitro cannot be done more than
14 days after fertilization or after nuclear transfer. ES cells used
for research should derive only from:a) Spare gamete or blastula after IVFb) Fetal cells after natural or voluntary selective abortion.
c) Blastula or monosexual split blastula by somatic cell
nucleus transfer techniqued) Germ cell voluntarily donated.
In India research on cloning through nuclear transplantationor embryo splitting with the intent to produce an identicalhuman being is prohibited. In Republic of Korea, reproductive
cloning is strictly prohibited. Under any circumstance this will beconsidered as criminal act. But ES cells research is acceptedwith regulation. Like Korea, Japan also prohibits reproductive
human cloning firmly and it imposes criminal sanction. Puttingof embryos into a human or animal uterus is also strictly
prohibited. However, it allows the application of these techniqueand other similar ones for research purpose as long as it is notallowed transplantation inhuman or animal. Reproduction
cloning is banned in Malaysia as well. But the therapeuticcloning of human embryo is acceptable as long as it reached
before 120 days of age.
Singapore has a complete ban on reproductive cloning but
permits therapeutic cloning under strict regulation. Embryos
created by IVF or SCNT for research purposes must have62

Eubios Journal of Asian and International Bioethics 19 (March 2009)strong scientific merit, potential medical benefit where no
acceptable alternative exists. Withdraw of stem cells from adulttissue, aborted fetuses and surplus embryo from fertility
treatment are allowed, as long as the embryo is les than 14days old.
Both the reproductive and non-reproductive cloning areacceptable only in Iran. For reproductive cloning it imposedsome regulations such as:
1. Identity of male or female donor should be known.
2. No junction of somatic and sex cell. Cell should not be
adulterered.
3. Person deal with clone should be specialist and aware of
secret of the operation.
4. Should not harm a future child in to human society.
Causes of Rejecting Human Cloning:
Human cloning is rejected by most countries because:
1.
Impairment of sanctity of life: Exercise discreet
manipulation over the process of reproduction, which isreserved or omniscience and an almighty creator.
2.
Risk of informed consent: experiment performed onhuman being, the subject must know the risks beforehand andgive consent. In case of human cloning, the embryo being
produced can not give such informed consent.
3.
Risk and inevitability of mistake: The techniques arestill in rudimentary stages. So it could lead to many
unsuccessful attempts. Before Wilmut succeeded in achieving
the birth of Dolly he was confronted with many experimental
pregnancies resulting in anomalies that are horrible.
4.
Loss of dignity: Many believe that life should have
mystery and a child comes about as the mysterious outcome of
the loving union of husband and wife.
5.
Little is known about potential side effects.
Manifestation of ill effects may emerge only after birth or whena cloned person reaches adulthood.
6.
What would be the age of clone person? Does it countfrom their birth or the date of birth of the donor?
7.
Biological diversity of the species will be jeopardized.
Conclusion
There is a need for further reflection in Asia and the Pacificabout human cloning, because of the varied aims. Some
researchers hope to relief the anguish of infertile couples bycloning technology. Some scientists set out cloning researchfrom curiosity or thirst for exploring truth; they want to discover
the mystery of the growth and development of human life
through this research. Freedom of research and discovery must
be respected but the scientific adventurism needs to bechecked.
References
1.
Castro, L. et al. Bioethics in the Asia –Pacific region: issue andconcern. In Ethics in Asia and the Pacific. RUSHSAP, UNESCO
Bangkok 2004
2.
Press release. United Nations Declaration on Human cloning .
nd82 Plenary meeting 2005
3.
Soltani AA. Human cloning in Islamic jurisprudence. In challenge
for bioethics from Asia. Macer DRJ (ed) .Eubios Ethics Institute,Japan 2004.
4.
Yanguang. Chines ethical view on embryo stem cell research. In
stAsian biethics in the 21 century. Sang-Yong S, Young –Mo K andMacer DRJ (eds), Eubios Ethics Institute 2003.
5.
Hee –Joo P. Cloning controversies in Korea. In challenge forbioethics from Asia. Macer DRJ (ed) .Eubios Ethics Institute , Japan
2004.
6.
Sriram Chakravarthi, Stem cell research and development instSingapore. In Asian biethics in the 21 century. Sang-Yong S, Young–Mo K and Macer DRJ (eds), Eubios Ethics Institute 2003.
7.
Benfu LI. The significance of human embryo stem cell researchstand its ethical dispute. In Asian biethics in the 21 century. Sang-

Yong S, Young –Mo K and Macer DRJ (eds), Eubios Ethics Institute2003.

News in Bioethics & Biotechnology
http://eubios.info/NBB.htm
International Bioethics Education ProjectNews<http://groups.yahoo.com/group/Bioethicseducation/>)

UNESCO Asia-Pacific School of Ethics
http://www.unescobkk.org/index.php?id=apse

Conferences
For a list of some ethics meetings in Asia and Pacific:
http://www.unescobkk.org/index.php?id=current_and_future_ev
ents

Asian Bioethics Association (ABA)<www.eubios.info/ABA.htm>

Send papers to EJAIB Editorial Office
Editorial address:

Prof. Darryl Macer
RUSHSAP, UNESCO Bangkok,
920 Sukhumvit Rd, Prakanong,
Bangkok 10110, THAILAND
Fax: Int+66-2-664-3772
Email: asianbioethics@yahoo.co.nz
d.macer@unescobkk.org
Send papers to the editor in electronic form if
possible. Please use numbered reference style, do not
use automatic footnotes or endnotes. Papers are peer
reviewed.
The journal is independent of UNESCO and the contents
are not endorsed by either Eubios Ethics Institute or
UNESCO, but are published in the spirit of academic
freedom.
EJAIB Editor: Darryl Macer
Associate Editors
Jayapaul Azariah (All India Bioethics Association, India),
Masahiro Morioka (Osaka Prefectural University, Japan).
Managing Editor: Nobuko Yasuhara Macer
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy (Turkey),
Angeles Tan Alora (Philippines), Atsushi Asai (Japan), Alireza
Bagheri (Iran), Gerhold Becker (Germany), Hasna Begum(Bangladesh), Minakshi Bhardwaj (UK), Christian Byk (IALES;
France), Ken Daniels (New Zealand), Leonardo de Castro (ThePhilippines), Ole Doering (Germany), Norio Fujiki (MURS Japan),
Tran Han Giang (Vietnam), Thomas Gionis (USA), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada), Margaret
Lock (Canada), H. Ahmad Ludjito (Indonesia), V. Manickavel(Nepal), Anwar Nasim (Pakistan), Mary Ann Chen Ng, (Philippines),
Jing-Bao Nie (China, New Zealand), Pinit Ratanakul (Thailand), Qiu
Ren Zong (China), Hyakudai Sakamoto (Japan), Sang-yong Song
(Korea); Noritoshi Tanida (Japan), A.K. Tharien (India), Yanguang
Wang (China), Daniel Wikler (USA), Jeong Ro Yoon (South Korea).

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