Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 23 (6) November 2013www.eubios.info ISSN 1173-2571
Official Journal of the Asian Bioethics Association (ABA)
Copyright ©2013 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page

Editorial: Ethics and Equity
189- Darryl Macer
The ethics of organ transplantation in theIslamic Republic of Iran
190
- Nader Ghotbi
Bioethics in Thailand: Perspective from Past to
Present and Unsolved Problems
193- Chutatip Umavijani
A Buddhist perspective on genetic enhancement 199- Ananya Tritipthumrongchok
Jaron Lanier’s Lock-In as Exemplified by Facebook 202- Jose Ma. Ernesto Jacinto Ybanez Tomacruz
Framework for Advancing Health Care in Pakistan 207- Sumaira Khowaja-Punjwani
Exploitation in Research: Utilitarian Considerations 212- Randall Horton
On the patenting of life: Ethical, medical, and economic
repercussions
218- Nitarshan Rajkumar
ABA Membership
New Editorial address:
Prof. Darryl Macer, Provost of AUSN and Director,
Institute of Indigenous Peoples and Global Studies,
American University of Sovereign Nations (AUSN),
8800 East Chaparral Road, Suite 250, Scottsdale,
Arizona, 85250 USA
Email: dmacer@au-sn.com darryl@eubios.info
http://au-sn.com http://www.eubios.info
Registered address of EJAIB: P.O. Box 16 329,
Hornby, Christchurch 8441, New Zealand

Editorial: Ethics and Equity
The Universal Declaration on Bioethics and Human
Rights (UNESCO 2005) includes an article recognizing
the global agreement that justice, equality and equity
are recognized as human rights in every country.
However, countries vary widely in the ways that they
establish just, equitable and loving social support
systems. This issue of EJAIB includes both general

papers as well as specific case studies to illustrate
ways that governments can deal with these ethicalprinciples.
Nader presents a case study of organ transplantationin Iran, which has implemented a system involving
payment for receipt of organs for transplantation thatmakes us re-examine broader norms that such acompensation system is undesirable. The regulation of
the system is interesting and worthy of study of how it
could be extended. At the end of this issue is a paper
by Randall that argues that a utilitarian system may be
useful for measuring how to manage exploitation in
research, rather than a deontological model that is
dominant.
Chutatip presents a review of issues in medical ethics
in Thailand, and reviews some of the laws that havebeen enacted to protect persons. There are examples
such as a cooling off period for gender change
operations, which are one of the medical services
available at low cost in Thailand. Ananya looks at
karma and the Buddhist perspectives on life, and how
this may relate to attitudes and practice ofenhancement of people.
Probably most readers are on Facebook, and thiswould be advised to reflect on the philosophicalanalysis of the concept of “Lock-in” that has beenachieved by facebook, explored by Jose.
Sumaira presents a comprehensive analysis of healthinequity and health care in Pakistan, that could beapplied to many countries and systems. How does yoursystem compare? This issue concludes with an essay
by an Indian student on patenting of life.
EJAIB welcomes papers from a variety ofperspectives to encourage dialogue. I hope readers will
support that dialogue, send in commentaries orarticles, and continue to support us throughmembership in the Asian Bioethics Association. We
see in this issue the first of papers from the Seventh
Kumamoto International Bioethics Roundtable, jointly
organized by UNU and Kumamoto University (KBRT7),thand from the 14 Asian Bioethics Conference held in
Chennai. Both of these were excellent meetings withmany papers presenting the results of thoroughresearch studies that will assist us in our goal of morebioethical societies. - Darryl Macer190

Eubios Journal of Asian and International Bioethics 23 (November 2013)

The ethics of organtransplantation in theIslamic Republic of Iran- Nader Ghotbi, MD, PhD
Professor, Ritsumeikan Asia Pacific University (APU),
1-1 Jumonjibaru, Beppu City, Oita 874-8577, Japan
Email: nader@apu.ac.jp

Abstract
Organ transplantation services, particularly kidneytransplants, have been provided in a fairly large
number and good quality in the Islamic Republic of
Iran since the 1990, and there are currently more than
25 kidney transplant centers that provide transplant
operations. From the ethical and religious point ofview, Iran has provided a flexible and relatively
regulated environment for organ transplantation,
especially regarding the possibility of unrelated livingorgan donation. This flexibility is mainly related to therole of ijtihad in Shi’a Islam where new rulings can beextracted by Shi’a jurists to facilitate the use oftechnologies that ordinarily might have been bannedby traditional Islamic rulings. The possibility ofmonetary compensation for unrelated kidney donors
in Shi’a Iran has helped expand the supply of donatedorgans, especially of kidneys, to a number almost
equal to the demand. The Supreme Leaders in Iranhave issued a series of fatwas that played a majorrole in legitimization of compensated organtransplantation from unrelated living donors. The main
ethical issue is the large number of donors whose
primary motivation is to gain monetary compensation
to deal with their financial needs, and the inability ofthe ethical and legal system to fully regulate themarket, to maintain fairness, and enhance altruism as
a motivation for organ donation. This issue is also
influenced by the economic hardship affecting mostpeople in Iran, and is not merely a consequence of
medical legislation to facilitate organ transplantation.
Keywords: Iran, Kidney transplants, Medical ethics,
Organ transplantation, Shi’a Islam.
Introduction
This paper presents the third part of a research
investigation into the three layer structure of bioethicaldecision-making in the Islamic Republic of Iran, and isbased on an analytical review of the religious andethical system of beliefs as well as the laws andpractice of medical care in contemporary Iran(1980~now). The so-called ‘three layer structure’refers to the basic ethical concepts, including ethicalrdtheories and religious beliefs as the 3 level, thendbioethical principles and laws as the 2 level, and thedecisions made on bioethical issues in medicine asst
the 1 level.
The area under investigation in this study is organtransplantation, and thus we discuss the bioethicalissues of organ transplants in contemporary Iran. Boththe first and second reports, as of 2011 and 2012

respectively, provided the background information
including the basic religious and ethical beliefs andrdtheories (3 level) of Shi’a in the Islamic Republic of
Iran; however, issues related to organ transplantation
provide an opportunity to revisit the 3rd level for abetter understanding of its policy implications.
Therefore we shall consider the 3rd level again but
mainly in the perspective of its impact on humanndorgan transplantation, before explaining the 2 levelstand the 1 level of bioethical decision structure inorgan transplantation.
rd

The 3 level (basic ethical concepts, ethicaltheories and religious beliefs)
rd
The fundamental question at the 3 level is about
the underlying ethical philosophy. The ethical thinkingof Shi’a Islam in Iran is based on prima facie
obligations similar to the views of the British
philosopher W.D. Ross (1877-1971). Thus, theunderlying ethical theory is not purely deontologicaland actions are not simply classified as right or wrong;
there are a number of obligations some of which may
be more important than others.
A shi’a Muslim is supposed to follow with various
actions he is obliged to, on the basis of a proper
ranking of obligations. Most obligations may beoverridden by a more important obligation, which isbasically the concept of prima facie ethics. Most moral
obligations are not absolute, as opposed to the
Kantian ethics, and exceptions are allowed dependingon circumstances. Actions may be judged
ethical/unethical based on the circumstances
surrounding them and the consequences of actions.
Therefore, what a Muslim does depends on both thecircumstances and the relative importance of various
obligations.
With prima facie way of thinking, there aresituations where one may need to take a ‘moral risk’,just as Ross mentioned in his ethical theory. Shi’aMuslims are strongly encouraged to make decisions
by ‘following’ the decree of a clergy (faqih) who hascompleted years of studying and training to attain‘ijtihad’. A decree in Shi’a comes from a ‘mujtahed’, a
Shi’a clergy who has extensively studied the Islamic
law of ‘shari’a’ and knows how to make the best
decision after ranking the various obligations under
the circumstances and specifics of a situation.
Under the theocratic system of Shi’a in Iran, duringth
the occultation of the 12 Imam, the Supreme Leader
may rule over the nation and can rightfully interpretthe Islamic law (shari’a). Therefore almost all
religious, ethical, political and other decisions in theIslamic Republic of Iran ultimately depend on theinterpretations of the Supreme Leader from Islam. The
decrees made by the Supreme Leader over all affairs
are considered as a legitimate source for decisionmaking by all authorities in the Islamic Republic of
Iran.
On the positive side, because actions may be
judged as ethical or unethical based on thecircumstances surrounding them, there is some formof ‘flexibility, meaning that religious decrees need not

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

be very rigid and can take a unique situation resulting
from new technologies into consideration to form new
rulings compatible with modern needs, including thoseused in organ transplantation. However, on thenegative side, when this flexibility extends to theextremes, it may seem to merge with ethicalrelativism. In the case of organ transplantation fromunrelated kidney donors who are compensated withmoney, ‘saving the life’ of a recipient is considered ofmore significance compared with the ethical questionof whether the ‘willing donor’ was financially coerced
to donate an organ. In this situation, the ‘consequence’of having ‘a life saved’ is deemed more important thatthe ‘action’ of paying for a human organ.
nd

The 2 level (biomedical principles and laws inIslam and Shi’a Iran)We need to first examine the basic Islamic principles
that are well recognized by the majority of Islamic
thinkers, and then examine the modifications made tothem in Shi’a Iran based on its use of ‘dynamic’ and‘flexible’ ruling through ijtihad.
The most basic law underlying the ethics of organtransplantation in Islam is the ‘principle of no harm’ (lazarar). This means that no transplantation would bepermitted if it is known to cause harm to the donor;
thus transplantation of heart as well as liver from aliving donor would not be permitted at all as it leads todeath and/or serious harm. However, this prohibition
can be sidestepped in the ‘context’ of kidneytransplantation for example, where there is negligible
harm to the donor while the life of the recipient can besaved. This is in fact the logic based on which organtransplantation has been permitted by clerics of Islam.
The greater significance of saving a life can be
implied from the following Quranic verse: Quran (5:35):“… and one who gives life to a person, is as he gives
life to all mankind”.
However, most Islamic jurists find it unacceptable toreceive monetary compensation for a human organ,
even for organ transplantation to save another person’slife, because there are limits on human’s ownershipover his/her body, God being the true owner, and it is
not up to a person to treat his/her body as a commodity
for financial gain.
Nevertheless, in shi’a Iran fatwas issued by theformer leader, Khomeini in 1988, and later by thecurrent leader, Khamenei in 2000, have allowed aconsiderable level of flexibility for organ transplantationin Iran. The widely publicized fatwas are related to theacceptance of brain death as termination of life, andpermissibility of organ removal from brain deadindividuals for transplantation. These fatwas became
the basis of an Act called the ‘Act of Organ
Transplantation and Brain Death’ that was approved by
the Iranian Parliament in 2000, formed into executive
laws by the Ministry of Health in 2001, and finallypassed by the Cabinet Council in 2002 (Zahedi, 2009).
Accordingly, the Professional Codes of Organ
Transplantation was issued by the Iranian Academy ofMedical Sciences on February 2008 which states(Zahedi, 2009): “Since protecting the lives of humanbeings is the most fundamental moral principal, theethics committee of the Academy of Medical Sciences(IRI) declares that kidney donation from living related
and unrelated volunteers is generally acceptable, andthe exchange of money as a reward of gratitude or agift for compensation is not considered unethical andshould not discourage this noble act, provided that:
1- The donor is truly willing to donate a kidney inhis/her right mind, free from coercion.
2- The donor undergoes complete medical check–up
and psychological evaluation and is found fit for theoperation.
3- There should be no medical contraindication forthe operation.
4- Donor should be able to get long term medical
attention after donation.
5- The medical team should have no role in theprocess of donation.
6- Donor and recipient should be from the samenationality; tourist transplantation is forbidden.
7- No one under the age of 18 and over 45 is
accepted for donation.
8- A national committee assigned by the ministry of
Health and Medical Education with the cooperation of
Iranian Transplantation Society will regulate andsupervisetherenaltransplantation
centersnationwide.”
Iran follows an ‘opt-in’ system where the patient or
the patient’s family must consent to the donation of theorgans. The cadaveric donations have been kept
altruistic and no monetary rewards have been paid tothe families of donors, except for a few cases where
funeral expenses were paid (Zahedi, 2009).
Iran is the only Islamic country that not only allows
monetary compensation of living unrelated donors but
also partially funds the payments to the donor. The
justification of shi’a scholars would be based on the‘levels/ranks’ of ethical value that were mentioned in
the first report (Ghotbi, 2012); they include wajeb,
mostahab, mobah, makruh and haram. Donating anorgan is highly mostahab (better done but still not
obligatory), so it is not wrong to pay/allow a gift or
reward as it is a highly desired ‘public good’ that needs
to be promoted by the state. Also, donating an organ
incurs some pain and inconvenience on the donor
though it does not seriously harm the health of ‘wellselected’ donors. The associated pain andinconvenience can be compensated by a reward, whilecadaveric donation does not incur such problems andtherefore need not be financially rewarded.
Although transplant tourism has been largely
controlled by laws which require the donor andrecipient to be compatriot, there have been manycases of Iranians who later became US citizens buthaving kept their Iranian passports, they travelled to
Iran to get a kidney transplant (Ghods, 2005).
st

The 1 level (the practice of organ transplantationin Iran)The Islamic Republic of Iran legalized the donation of
kidneys from living unrelated donors in 1988. A system
was created by the government to fund and regulate

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

the transplantation process through a third party called‘Association of Dialysis and Transplant Patients’.
Donors would receive a gift of 10,000,000 Rial (equal
to about USD 2,500~2,000 in 1990’s and early 2000’s,
respectively) from the association, plus in many cases
another agreed upon sum of money directly from therecipient’s family which in average was about two times
the formal amount.
In 2006, the formal pay was increased to 50,000,000
Rial to make up for the severe inflation in Iran; thevalue of Iranian currency has decreased from about
4,000 Rial for USD 1 in late 1990’s to about 30,000
Rial for USD 1 in recent times. This has caused donors
to expect a much larger amount of compensation fromthe recipient of the kidney because the governmental
funds did not increase at the same scale. Recipients
may be paid between 100,000,000 to 400,000,000 Rial
(3,300 to 13,300 USD) depending on the size ofdemand versus supply as well as the ability to pay (byrecipient) versus the need for money (by potential
donors).
Because the kidney transplant system only relies on
ABO compatibility (not HLA matching), it is easy forpotential donors to advertise their kidney to potential
recipients with just a phone number and their bloodgroup written next to it; many photographs have been
surfaced and widely shown on the Internet of suchgraffiti on the walls near the site of the “Transplant
Association”. The transplant centers have continued
with their policy of only requiring ABO compatibility
citing their own studies which show no statisticallysignificant improvement when HLA compatibility waschecked; this has facilitated the advertising of kidneys
for sale by potential donors, as mentioned before.
The donors are supposedly under the coverage ofgovernmental health insurance for life, but because of
the nature of the insurance and the wide gap between
formal fees and the private sector, this coverage may
not be complete. It is worth noting that some experts
have already suggested that a reward of about
USD90,000 would be a fair compensation considering
the required checkups and possible expenses to thedonors of kidneys in the US (Matas, 2003). Apparently
the important issue for these experts has been the‘fairness’ of compensation, rather than the basic issueof whether monetary compensation for human organs
is ethically defensible or not.
Discussion
A large number of people are being affected bychronic diseases such as chronic renal failure, whichleaves them with few options to survive other thandialysis and an organ transplant from another human.
The demand for human organs is much larger than the
supply that can be provided through cadaver organs
plus brain dead individuals who have consented toorgan removal. One of the consequences of monetarycompensation of donors is saving the lives of more
people, but we should not ignore other social
consequences such as the use of human body as amonetary asset and its being targeted for raisingmoney by individuals in need who may not necessarilybe the donors. It would be very difficult to assure a lackof coercion especially in situations that economy isbad, loans are piling up, and there are few otheroptions to raise revenue. This situation is alreadyhappening in Iran and the recent economic pressures
have only aggravated it.
Although it is illegal to trade kidneys in mostcountries in the world, it is a common undergroundpractice at least in a number of countries like Russia,
Turkey and South Africa (Major, 2008). Apparently, thelegal and ethically approved sources of kidney fortransplant, including cadaveric donors, brain deaddonors, and living related donors are not enough tomeet the high demand. An especially disturbing
phenomenon is the practice of ‘transplant tourism’
whereby rich recipients travel to a developing country
where they may buy an organ, such as a kidney, froma living unrelated donor.
A kidney transplant does not significantly harm thedonor even in long-term, but is associated with somerisk and suffering such as those associated withbleeding, anesthesia, not having an extra kidney forpossible injuries in the future, etc. Provision of life-timegovernmental health insurance to donors helps reduce
the associated risks but does not fully eliminate them.
To allow monetary compensation to cover for the pain
and suffering of the donors and the small extra risk has
been supported by some experts but they recommendthat the level of monetary compensation should be fairenough; a few experts have suggested a figure ofabout USD 90,000. The amount of money that Iranian
donors negotiate for is in a far smaller range of about
USD 3,000~10,000 but still mainly depends on theability of the recipient to pay, and the negotiation
leverage of the donor based on unstable and everchanging economic conditions in Iran, as well as thesize of the ‘supply’ in the matching ABO blood group.
Tens of thousands of people in Iran have been able
to follow a normal life without reliance on dialysis after
receiving a kidney from an unrelated living donor. A
significantly larger number of lives, those of kidney
recipients, have been saved as compared with thephysical harm to donors of kidneys. An ethicalconsequentialist may find this fact convincing enough.
However, there are other ‘social’ consequences, forinstance through a devaluation of the ‘sanctity’ ofhuman body over financial needs of the donors or theirfamilies, as well as the ‘deontological’ issue of allowing
people to sell their body organs for financial gain. The
latter is a special concern in Islam and the main reason
why transplantation from unrelated kidney donors isbanned in all Muslim countries except for Iran.
Having said that, it cannot be denied that the flexible
attitude of the Iranian government towards the use of
unrelated donors may have avoided from moreunethical practices such as underground clinics run byillegal human organ traffickers. Patients needing atransplant may have largely benefited from a practicalsolution to their ‘life or death’ situation, and the donors
may have also been able to use the reward in apositive way without suffering from serious bodily harm;
it is also hoped that in the future there will be better

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

solutions, as the number of cadaveric and brain deaddonations increase; currently they are only about 10%of the total number of transplants. However, we cannot
deny the probability that donors and recipients, as wellas surgeons and the whole transplantation system
might have made different decisions if they were better
informed about the ethical nature of such transactions
and discussed their implications for society at large inmore detail. I would argue for discussions to reassess
and revise the system to help keep it in line with themorals of the society and the sanctity of ‘everybody’slife.
The experience of Iran with kidney transplantation so
far may be interesting to other nations, whether Sunnior Shi’a, Muslim or non-Muslim. I would like torecommend long-term follow-ups of both donors andrecipients of kidneys to gather more reliable
information about the consequences of this system inlong-term. It is unfortunate that many of the papers
published by Iranian surgeons involved in thetransplantation system appear to deny thedisadvantages of the current system and attempt toonly focus on its advantages for the recipients in termsof life years saved. Fairness of the system, the longterm quality of life of both donors and recipients, aswell as the willingness of the donors to recommend
such a procedure to their beloved relatives, family andfriends could be further investigated in Iran.
Acknowledgements
This research has been supported by a grant from theJapanese Ministry of Higher Education, Culture, Sports,
Science & Technology (MEXT), and supervised by Professor
Takao Takahashi, Graduate School of Social and Cultural
Sciences, Kumamoto University. I would like to especiallythank Professor Takahashi as well as Professor Darryl
Macer, for the hard and diligent work of organizing andfacilitating the associated research activities. This paper waspresented at KBRT7.

References
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Brain Death: Recent Ethical and Religious Considerations
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An Ethical Review of the Iranian Model. Kennedy Instituteof Ethics Journal 16(3): 269-282.
3- Bhan Anant, Majd Mina, and Adejumo Adebayo. 2006.
Informed Consent in International Research: Perspectives
from India, Iran and Nigeria. Medical Ethics 3(1):36-41.
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5- Clarke Morgan. Islam and new kinship, reproductive
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Behzad.
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Bioethics in Thailand:
Perspective from Past to
Present and Unsolved
Problems- Chutatip Umavijani, Ph.D.
Philosophy Department, Faculty of Liberal Arts,
Thammasat University,Thailand
Email: chujid2@gmail.com
thSince the 13 century, during the Sukhothai Period,
traditional and herbal medicines were used by monks
and village healers to take care of the sick in Thailand.
thNot until the modernization period in late 19 century,

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

modern medicine was introduced to the country withthe establishment of the first modern hospital in the
country in 1886. Hospitals and medical schools
followed the American model. Then Western medicine
has replaced our traditional medicine. No doubt that
Thai people benefited a lot from modern medicine but it
raised many ethical problems. Bioethics wasintroduced into Thailand only 15 years ago with theAmerican and European model, Thai modern medicine
has created many problems that are difficult to solvewith from the traditional and Buddhist background. The
complex ethical problems concerning euthanasia, rightto die and right to live, human experimentation, organtransplantation, and the new productive technologies
are emerging as a result of using hi-tech medicine.
Since the year 2004, Thailand has become a global
hub of medical tourism with world class facilities, which
had raised many ethical questions and the Thaigovernment has to have some laws to regulate some
practices.
This paper will elaborate upon the problems andwhat should be the solution with the Buddhist
background of the people. The problem of medical
health in Thailand is not only the emergence of ethicalproblems in bioethics but also the separation ofmodern medicine from morality and spiritual
dimensions. Thai traditional medicine has Buddhist
values as its main component. In the last hundredyears many Thai doctors were trained in America or
Europe and brought back modern medicine with freemarket ideology, which value wealth over humanneeds or person. The health care can benefit those
who have, and those who have not cannot access thebenefit. More than 70% of Thais in the rural areas
cannot have good health care. This is another problem
that will be discussed in this paper.
I. Present situation: health care and problems
The present situation of medical health in Thailand
is separated from traditional medicine and ideology
background of the country. Modern medicine isanalytic, i.e. it separates the physical from the mental,
and the pathological part from the other parts of human1system. It lacks religious values and spiritual aspects.
In Bangkok, many private hospitals use the hi-techmachine and medicine to patients.
End of life care
Living Will: The National Health Act of Thailand
granted that a person is given the right to make a living
will to refuse public health service which is provided toprolong his terminal stage of life. This law was enacted
in 2007. But not many Thais are aware of this law evennow. Most of the rich relatives even the middle classes
want to prolong the death of their loved ones throughhelping machines and other means no matter if thepatients desire or not. The problem of the right to die
has not been discussed among doctors and patientswidely. Not understanding philosophy of Buddhism
1

Ratanakul, Pinit. ‘Bioethics in Thailand’, Bioethics in Asia
pp.98-99 Eubios Ethics Institute 1998.

clearly Thais are facing real dilemmas of life and death.
Pulling off the plug of patients who are brain death; canthis be considered as killing? With the Buddhist
background and traditional belief no one wants to do
the job. There are many cases also that doctors andthe closed relatives use technology to prolong the life2of patients without consideration of the patient’s will.
Thailand also has Hospices and Homecare asalternative terminal care programs that give strictly
non-curative care. They also have palliative careprogram. In order to be sure that the final days of apatient are pain free and comfortable. And also support
to family whose loved ones are facing an incurable
illness. The desired result of all palliative care is toimprove the quality of life of a patient. The professionalteam works with the patient and family to make surethat the patient dies with dignified and comfortable
death. Through this care the patients are treated both3
physical ailments and psychological needs.
Euthanasia-Killing or Letting-Go:
This is a controversial subject in all societies as it
involves the ending life of a person. In Thailand,euthanasia is not expressly allowed neither is it
expressly prohibited. Active Euthanasia qualifies as
murder under Section 288 of the Criminal Code:“Whoever commits murder on the other person shall bepunished with death, imprisonment for life or
imprisonment of fifteen to twenty years”.
And also Physician Assisted Suicide – qualifies asassistance of suicide under Section 307 of the Criminal
Code: “Whoever practices cruelty or employs similar
factors on person who has to depend on him or for
substance or any other activities in order that such
person shall commit suicide, or if suicide has occurredor has been attempted, be punished with imprisonment
not exceeding seven years and fine not exceeding
fourteen thousand baht”.
We can see that the Thai Criminal Code, euthanasia
consider as unlawful, but under the Civil Code is notnecessary in the following.
“When euthanasia, whether active or passive, isperformed without the patient’s consent, the doctor will
be charged with a tort, and is required to pay thereparation. In case where euthanasia is accomplishedwith the patient’s own consent, the principle volunti non
fit injuria is applied as a general principle of law eventhough the very same act would be criminally4
condemned”.
As Thai society changes, people are more involved
and concerned about human rights. The problem of
euthanasia are part of the expression of one’s freedomof decision making about the Human Rights and Civil
2

In the cases of Buddhatas Bhikku, Dr.Pradit Tansurat,
Poonperm Krairish, had been hospitalized for sometime
before their death.
3
Kelly, Katherine. Mutetwa, Batsirai. Novoson, Lisa.
Palliative Care in Thailand: Hospice and Homecare: A
Framework for the Assessment of Costs and Benefits.
www.wpi.edu/Pubs/E-project/Available/E-project.../ Deliverable.pdf

4Santivasa, A.P. Legal Aspect of Euthanasia in Thailand:
Problems and Prospects.

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

Rights laws is concern. Passive euthanasia is when
the patient’s death resulted from withdrawal of thenecessary treatments. There are necessary consentsfrom the patients or the relatives of the patients.
As mentioned a person is given the right to sign aliving will to refuse the public health service, the person
who is ill may make an “advance directive” which is a
written document stating the wishes of a patient
regarding medical treatment which may involve
decisions such as ending his life.
Because of the incorporation of the provision above
mentioned in the National Health Act of Thailand, it
became know to the world that the country allows
euthanasia in its jurisdiction. Nevertheless, the battle ofthe legality of euthanasia in the country is still on its
peak and as a country which primary religion is
Buddhism, euthanasia will always reap criticisms fromdifferent sides of the society. It is a fact that pro
euthanasia lobbied for the importance of a law allowing
the same while those against still remain to defend theteaching of Buddhism- abstention from destruction of5
life.
Buddhist teaching and interpretation towards theissue will be introduced and discussed as a challenge
by the problems and questioning the use of modern
technological medicine, later on.
The right to live: Problem of abortion has been of
great concern to public and health department since
the discovery of almost 2000 fetuses in Bangkok,
2010. The event alarmed the Thai government andespecially the Senate to put the Pro-life Reproductive
6
Health Bill in the country. Article 305 of Thai Penal
Code states that abortion is illegal, except in cases
committed by a medical practitioner and is considered
only necessary if there is a danger to the health of themother or when the pregnancy is due to sexual
offenses as rape and incest or the fetus severely
handicapped.
Abortion has been considered as a sensitive issue
which alarmed many interested groups such asactivists and feminists. So far nothing really changed
according to the law, but the issue remains a problem.
Those who support abortion consider that it is not acrime when the fetus is aborted, as the fetus whileinside the mother’s womb is not yet considered ashaving any legal right as a person under law, until it
was completely delivered and alive. The feminists who
support abortion argued that abortion will eliminate
gender discrimination in Thailand, as the law allowing
abortion will promote the “right of woman to choose”. It
will also reduce the high rate of woman seeking illegal
abortion. In legalizing abortion in Thailand according to
the feminists will also reduce the rate of death among
woman caused by unsafe abortion.
The problem of abortion still remains. There aremany arguments from those who are against abortion,such as the life of unborn fetus should also beprotected as it is given value as a being. If the law
allows abortion, the whole traditional values andcustoms are out of date, with the Buddhist backgroundthose who against legalizing abortion consider thatabortion is a sin. The questions of abortion have to becarefully considered, from the realistic point of view,
Buddhist point of view and social point view.
The Senate considered an immediate passage of
the Pro-life Reproductive Health Bill which
concentrated upon preventive measures that will giveawareness to Thais and will give information on
effective Birth Control Methods. In the Bill, thegovernment is mandated to provide accommodation foryoung mothers as well as their newly born babies’ forfree health care. Legalizing abortion is not the solution
to the high rate of population growth. They try to giveeffective sex education rather than amendments to7legal abortion.
Organ Transplantation has been practiced in
Thailand since 1972 first at Chulalongkorn University
Hospital.
Thentransplantation
was
gradually
developed, and now bone marrow, kidney, liver, heart,and lung transplants are common. Heart and lungtransplantation are undertaken in 26 hospitals around8
the country. Kidney is the most transplanted organ.
The demand for organ transplantation has increased
and disproportionately increased the demand for
donation, leading to the problem of organ shortage. For
example, in June 2002, there were 1,029 patientsregistered for organ donations, and only 200transplantation cases were operated. It will takeapproximately 5 years to treat all patients on thewaiting list without new registered patients.
Law and order need to step in the process oftransplantation, as in 1997-2000 there were scandals
about illegal kidney transplantations. The news had
impact upon the transplantation system which led tomany regulations on transplantation. After 1989,
rumors about organ selling in Thailand and othercountries gradually spread. During 1997-2000 there
were scandals on kidney trafficking in a private
hospital. This was reported to the public throughout themedia and had major repercussions on public trust intransplantation. The number of donations andtransplantations
decreasedsignificantly.
Thenregulation of transplantation were established, there
were consumer protection in transplantation system,with rule and regulation and enforcement agencies.
Patients who need transplantation must register in a
hospital capable of performing transplantation at one
hospital only. There were regulations set up in order tomake the best and fair in transplantation.
In 1989, the Thai Transplantation Society was set
up that has great concern and interest intransplantation, especially in academic and treatment
aspects. The problems of transplantation in Thailand
are the lack of organ donation, expensive medicationand operations that the poor cannot access. There isno specific law in Thailand to control all persons

75

http://www.thailandlaw.org/euthanasia-in-thailand.html
6
Thailand Law, thailandlaw.org.

Thailand Law, thailandlaw.org.
Regulation Organ Transplants Thailand HEFP 04-03 –WPOR _03. pdf p.3

8

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Eubios Journal of Asian and International Bioethics 23 (November 2013)9involved in transplantation. There are needs toincrease knowledge and interest among the people
and physicians that can improve the donation rate in
hospitals such as from the brain death patients. The
promotion of knowledge to contribute organs to the
public is very important. The trust of the general
population should help to increase donation andtransplantation.
II. Thailand: A global hub of medical Tourism by
the use of high technologies and new productive
technologies: Assisted Reproduction, Gender
Reassignment Surgery, Stem Cell Therapy andResearch, Cloning, Face Transplants and Cancer
Treatment and Research.
New advanced technologies are being used in allleading hospitals and private hospitals in Bangkok.
World class facilities offering a wide range of medical
treatments are now located within the country. Welltrained doctors are expert in techniques of the new
productive technologies, such as assisted reproduction
practice widely. There are many regulations issued asfollows:
Assisted reproductive technologies (ART) in
Thailand: 2001-2007 results generated from theART Registry, Royal Thai College of Obstetricians
and Gynecologists. Executive Board of Medical
Council of Thailand has set up an ad hoc committeethat established the regulations for practicing assisted
reproductive technology. The committee assigned theRoyal Thai College of Obstetricians and Gynecologists
to supervise and take charge of the administration andformulate an annual report in accordance with the Thai
Medical Council Declaration. The regulation was finallyapproved on 9 October 1997. It was announced in theRoyal Gazette on 26 December 1997 and since thenthe prescription of standard measures for ART practicehas been effected. All licensed ART centers are
obliged to submit annual reports on the number ofpatients, cycles, ART techniques and treatment
outcomes to the Reproductive Medicine Subcommitteeof the Royal Thai College of Obstetricians andGynecologists. Data from all centers were aggregatedand analyzed retrospectively. Despite many limitations,the data provided in this report will help patients,
clinicians and policy makers understand the current
10
situation of ART practice in Thailand.
Gender Reassignment Surgery: Thailand isfamous for the transgender surgery. There are many
private hospitals and clinics that offer a variety oftreatments for patients who wish to change theirgender. There are regulations made by the Medical
Council of Thailand in 2009, for doctors performing sex
change operations to be registered with the Medical
Council. And doctors must check and give treatment
for any post-operative complications. Before an
operation, the transgendered person must live as the
opposite sex for a year while under hormone therapy,
9

Ibid., p.27
The Authors. Journal of Obstetrics and Gynecology
Research, 2010 www.ncbi.nim.nih.gov/pubmed/21272157

10and consult psychiatrist for the hormone too. And at
least two psychiatrists must give letters of approval forthe person to receive gender reassignment surgery.
Stem cell Research and Therapy: Stem cell
treatments and research are regulated in Thailand by
central authorities. But before 2009, no government
regulations were in force. Medical institutions were11
responsible for regulating themselves.
Afterinternational criticism of Thai hospitals and clinics
offering many unproven and potentially dangerous
stem cell treatments, the Thai government decided totake action by regulating the use of stem cells by
12central authorities. The Medical Council is the main
regulatory body overseeing stem cell research. Doctors
giving stem cell therapy have to be certified by the
Medical Council. Any institution, public or private,wanting to do stem cell research must first get theapproval of the Medical Council’s ethical committee in
addition to their home institution’s ethical committee.
And also the Ministry of Public Health which oversees
the Food and Drug Administration (FDA) also has a
hand in the regulation of stem cell therapy. In 2009, the
FDA said stem cells and their products would be
13
regulated as drugs.
The FDA also banned theadvertising and sale of cosmetic products containing
stem cells, and warned against facial treatments
14
involving stem cells.
Cloning: We remember mostly about cloning Dolly
the sheep in 1997, and after that there was a Thai
movie named Cloning and not a popular one. In 2005,
a Thai scientist began cloning super cows after theimportation of U.S. Cattle was banned, and the same
year The United Nations General Assembly adopted
the Declaration on Human Cloning, which prohibitedthe use of human cloning if it violated human dignity. In
Thailand, therapeutic cloning is allowed, but the15
reproductive cloning is banned.
Face Transplants: This technique may not yet behappening in Thailand, but face procedures are
11“Stem Cell Therapy in Thailand,” Health-Tourism.com,
2008,
http://www.health-tourism.com/stem-celltherapy/thailand/.
12
Sirinart Sirisunthon and Pongphon Sarnsamak, “NewStem-Cell Regulation Draws Flak,” The Nation (Bangkok,
February5,2010),
http://www.nationmultimedia.com/home/2010/02/05/national/
New-stem-cell-regulation-draws-flak-30121899.html.
13“Stem Cell Therapy in Thailand.”14
Pongphon Sarnsamak, “Medical Council to Punish Doctors
Who Do Stem cell Therapy,” The Nation (Bangkok, July 30,2008),
http://www.nationmultimedia.com/home/2008/07/30/national/
Medical-council-to-punish-doctors-who-do-stemcell-300793600.html; Pongphon Sarnsamak, “FDA Warns About
Facial Treatments,” The Nation (Bangkok, March 2, 2008),
http://www.nationmultimedia.com/home/2008/03/02/headline
s/FDA-warns-about-facial-treatments-30066981.html.
15“United Nations Declaration on Human Cloning
A/RES/59/280,” Genomics Gateway, March 29, 2009,http://www.brad.ac.uk/acad/abtwc/gateway/HEALTH/Cloning.
htm; “GENERAL ASSEMBLY ADOPTS UNITED NATIONSDECLARATION ON HUMAN CLONING BY VOTE OF 84-3437,” n.d.,

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

common. With Google search will bring plenty of clinics
and hospitals that perform cosmetic facial procedure orcalled facial rejuvenation. Some examples are facelift,
eyelid surgery, cheek implants, jaw surgery, lip andnose surgery.
Cancer: With increasing rate of cancer, the Thai
royal family has patronized cancer treatment andresearch facilities. Researches on cancer are the focus
from many research centers, they are interested inusing Thai natural products to treat and prevent thedisease.
Medical Tourism and Practice: People from allparts of the world are drawn to Thailand for good
medical care and comparatively cheaper rates. The
cost of surgery in Thailand can be one-tenth or less ofwhat is in the United States or Western Europe.
Thailand also has at least 450 hospitals withinternationally trained medical staff that specialize inneurosurgery, dental surgery, heart surgery, andcosmetic surgery. Under the Thaksin regime, June
2004 the government tried to promote medical tourism,
created a strategic plan that would offer medical
services to at least two million tourists by the year
16
2008. This focus on big business has lead to theprivatization of many Thai hospitals in four majorcollaborations: Bumrungrad, Bangkok, Thon Buri, and17
Phyathai are now the leading medical tourist centers.
For example, the Bangkok Dusit Medical Services is amajor collaborative group with the chain of 14 hospitalsof the Bangkok Hospital Group. That offers a deluxe
service and amenities on par with five stars hotels. The
ethical problems and results of the medical tourism inThailand will be discussed later.
III. The Problems and Solutions of Bioethics inThailand from Social and Buddhist Perspective
In Buddhist ethical thinking, compassion andinterdependence (the connection of all) are two
fundamental values. Compassion implies: first, respect
for the right of an individual to make choices or express
autonomy. Second, one will act the best with theinterests of other in mind that is being beneficence.
Third, non-maleficence, with compassion one will dono harm for others. And fourth, justice that one cangive fair treatment equal to all. Beauchamp andChildress already stressed these in their Principles ofBiomedical Ethics. These ideologies included theconcepts and respect of human dignity and humanrights as well. One has to have compassion to oneself
which enables one to have dignity and know one’s
rights. One also needs to understand the concept ofinterdependence thoroughly. The interesting concept ofinterdependence does not lead the self to be isolated
and autonomous, but with the relationship to others,
the fellow humans, society and nature are unlimited oftime and space. As it means one can exercise
16

Saniotis, Arthur. Changing ethics in medical practice: A
Thai perspective. Indian J Med Ethics 2007;3:24-5.
17____________. A Medical bioethics and medical tourism inThailand. Paper to be published in 2007 in Journal of theThailand Medical Association.

individual rights with respect and consideration of its
effects on the others, so called responsible
18
individualism. The Buddhist based Thai approach isholistic: human beings are seen as being comprised ofphysical, mental, emotional and spiritual elements.
These aspects are interwoven with one’s social andphysical environments. Health is viewed as the
harmonious interplay of all the forces in accordancewith the eightfold path of Buddhism. Disease isconsidered as an expression of disharmony, which
19
prevent a person from living in a holistic way.
In the old Thai Buddhist approach, disease may
result from surrogate agents such as ghosts, demons,
who may possess or afflict the person. There will be aseries of rituals which are performed by shaman orsome Buddhist monks who mediates between humanand spiritual world. The Buddhist concept of karma(one’s own action) contributes also to individual’s stateof health and illness. That health and disease areinterpreted as the effects of positive or negative karma
which may be accumulated from the previous act orpass life. Thai Buddhism prescribes that human beings
practice morality (sila), discipline (Samadhi), andwisdom (panna) in order to live the life well, able todiminish the negative karma and have good health.
Death and dying: Thai Buddhist accepts death aspart of their life with no difficulty as common words areusually represented about life: ‘being born, getting old
and die’. But the question of how to die is more
important. Active euthanasia is certainly rejected bothby law and Buddhist morality (sila, the first principle is
not to kill). But passive euthanasia or letting go of life ismore acceptable to take into consideration. In thesense of letting go or let die is to let go of the person in
the natural process, and can be an act of compassion,
not to go against nature and prolong the suffering of
the patient or relative, especially the patient total brain
death and no hope for recovery.
Hospice and Living Will: The hospice care is
accepted well in Thai Buddhist society as it is a natural
end of life. It shows holistic approach to health carethat focusing on the entire person. Buddhism considers
the last stage of life that is calm and conscious states
are meaningful to next life or the reincarnation. Dying
with consciousness is important for the next stage oflife. “Buddhist literature emphasized the importance ofmeeting death mindfully since the last moment of one
life can be particularly influential in determining the20
quality of the next rebirth.”
Doctors and nurses with the practice of compassion
provide palliative care, lead the patients to have lesspain and ready to go; patients can have a meaningful
life at the end. The ‘living will’ is able to help one die
18

Ratanaku, Pinit. Bioethics in Thailand: An Update
http://muse.jhu.edu/login?auth=0&type=summary&url=/journ.
19____________, Buddhism, health, disease, and Thai
culture. In:H Coward and P Ratanakul, editors. A crosscultural dialogue on health care ethics. Waterloo, Ontario;
Wilfred Laurier University Press: 1999. p.17-33
20
Hughes, James J., Keown, Damien. Buddhism andMedical
Ethics:A
Bibliographic
Introduction
http://www.changesurfer.com/Bud/BudBioEth.html

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

with dignity. Hospice and ‘living will’ enable one to havehumane treatment that is still possible in the society.
More and more people are also aware of ‘living will’,and wish to die naturally in the last stage of their life, as
they believe this is the Buddhist way to face theinevitable death.
Right to live: The tragic event in Thailand in 2010that 2000 fetus were found showed that Buddhist
ideology had been ignored by many young people.
Thai
traditional
Buddhistbelievedthatthetransmigration of consciousness occurs at conception
and therefore that all abortion incurs the karmic burden
21
of killing. Any killing is successfully done consisted ofthree parts, first the mental effort, second theintensification of the desire to kill, and thecomplete act of killing the victim, stated by
Buddhaghosa, the well know Theravada Buddhist
Monk. He further said that the karma of feticide would
22
be greater than that of killing villains in self defense.
As we saw above mentioned that abortion in Thailandis against the law, what we need in Thailand is goodsex education and methods of contraception. There
should be movies and stories to youngsters andteenagers about prevention of pregnancy, abortion,and the effect upon the mother physical andpsychology and the fetus. There are many stories thatthe event can never erase from one’s memory, which
are painful and brought great suffer to the mother andthose surround even with to those who had a lawfulabortion.
Thailand: Medical Hub and High Tech Medication
benefit to whom?
Many people from all countries come to Thailand for
medical treatments. Doctors and nurses areconcentrated in those high quality world class hospitals
to serve foreigners and well to do patients. Is the ideaof leading the country into a medical hub a wrong one?
This neglects those who live in the countryside which
are more than 70-80% that lack good medical care.
The much higher medical expenses and better
professional care in private hospitals are beyond thefinancial capacity of most Thais. And also the shortageof medical practitioners, only 25,815 physicians were23
filled out of 31,039 in 2005.
This consuming and capitalistic society drives
people to have more than what are necessities, Thai
people are also the victims of the system. Even if theKing of Thailand always stresses sustainable
development, and the “sufficiency economy” hasbecome a global dialogue for many nations. And his
ideas became a great model for this ecological problemof the world. But it seems to have little concern for
those commercialists and politicians. As Socrates said,‘Those who never know who they are can never besatisfied with themselves.’
Buddhism in Thailand is interesting, as according to
the survey there are about 90% Thais are Buddhist.
Thais observe and practice Buddhist rituals and rites
but to really understand the philosophy of Buddhism or
not is the question. Had the Thais known thephilosophy of Buddhism, many high tech technologies
that are being use now will be irrelevant, such astransgender surgery, face transplants, cosmetic
surgery etc. Buddhism can lead people to understandlife and accept life as it is. There is no need to havesex change, as one should be satisfy with oneself.
Face transplants, cosmetic surgery also come fromdissatisfaction of one self. Right now we have so manykathoey, after the sex reassignment surgery, (they are
more beautiful than many ordinary Thai ladies).
Thai Buddhism links physical beauty to “moral
purity” improving upon one’s physical appearance can24have added spiritual benefits. This understanding is
upside down from true Buddhist philosophy. According
to Buddhism, those who practice well both in morality(sila), maintain discipline (Samadhi) and gain wisdom
through practice of meditation (panna) are goodlooking, and maintain one’s dignity in life. But those
who want to have sex change are willing to pay
multiple and expensive surgeries for their relentless
25
pursuit of pseudo physical beauty.
How can the Thai doctors, nurses and public befully aware of the linkages between modern medicine
in bioethical problems? The Thais also have to learn
how to apply Buddhist philosophy and ethical principles
to the problems. What is lacking in Thailand is asystematic reflection on these problems within
26
Thai/Buddhist cultural framework.
Highly advanced technologies in Thailand such as
assisted reproduction, gender reassignment surgery,stem cell therapy and research, cloning, facetransplants etc. are important for the Thais toinvestigate how these high technologies areappropriate to their life. Do Thai Buddhists understandlife in a holistic way or not, that physical, mental
emotional and spiritual cannot be separated. To live inharmony with nature, not against it, to understand thatone’s action (karma) effects upon one’s life.
As mentioned before many Thais hardly understandand practice Buddhist philosophy, they do not realizethat they are responsible for their own actions notmatter what they do. And to understand that all things
are interdependence or Dependent Origination, allthings arise in dependence upon multiple causes andconditions. This is the basis of the key concept of
Buddhism. Buddhist wisdom is one that can gain
through meditation is the realization of the threecharacteristics of reality-impermanence, suffering andno-self. But it will take time and great effort to be able

21

Ibid., p.4
Hughes, James J. Buddhism and Medical Ethics: A
Bibliographic
Introduction
p.5
http://www.changesurfer.com/Bud/BudBioEth.html
23
Saniotis, Arthur. Changing ethics in medical practice: aThai perspective, Indian Journal of Medical Ethics
Vol. IV No1. January-March 2007.
22

24

Saniotis, Author. Changing ethics in medical practice: A
Thai perspective. Indian J Med Ethics 2007;3:p.25
25
Ibid., p.25
26
Ratanakul,
Pinit.
BioethicsinAsia.
http://www.eubios.info/ASIAE/BIAE98.htm

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

to realize these characteristics. If the Thais truly
understand Buddhist ideology the country will progress
they way it is now. They will not measure success bymaterial gain, but by morality with compassion. They
will not prolong death by only using high technologies,
they will not have euthanasia and abortion, as nature
will take life itself. They will live a life in harmony withnature, not to control it. They will accept who they are,not who they want to be, so there will be no sex
surgery, face transplant. They will have a good
distribution of health care to all, not only concentrate in
big cities like Bangkok.
The urgent problem: the limited of health careresources. The basic health care services are still
inadequate for 78% of the Thai population who live inthe rural areas. These people are poor and in need ofhealth care services more than affluent people in thecities like Bangkok. The fair distribution of health care
to all sectors in the society is needed.
Conclusion
Education is able to lead for the better in thesociety. Bioethics courses are being offered in Thai
universities that can lead people to be more aware of
the problems in bioethics. The country has gone too far
to realize the problem and solve in a Buddhist way.
The real obstacle is that the Thais are not truly
understand Buddhism. They only call themselves
Buddhist as it is registered as their “official” religion but
many do not follow the philosophy. They do notunderstand sustainable development as a way of life.
Bioethical problems of the Thais are very difficult tosolve, as the people have to think for themselves, tounderstand their situations, and to have the knowledge
to be able to see the whole structure of life, the wholeworld, and philosophy. How are things related andconnected to all? At the moment, they are like blind
persons walking in the mist of a fog not knowing andseeing things clearly, and they do not know what
direction they should take. By the time they reach theend, they will realize the vanity of life itself. Hightechnologies that were invented are like a knife, one
can use for one end that can be very useful, and theother end one can kill oneself. If the Thais understandthe meaning of life and death, the interdependence inall things, the values in life, compassion to everyone,technologies in their hands can be used to help one
another for the better.
Bibliography
Beauchamp, Tom L. and James F. Childress. Principles ofBiomedical Ethics, Third. ed. Oxford: Oxford University
Press. 1989.
Hughes, James J. and Keown, Damien. Buddhism andMedical Ethics: A Bibliographic Introduction, Journal of
Buddhist
Ethics,V.2,
1995.
http://www.changesurfer.com/Bud/BudBioEth.html
Kabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdomof Your Body and Mind to Face Stress, Pain and Illness.
New York: Dell. 1990.
Lindbeck, Violette. “Thailand: Buddhism meets the Western
Model,” The Hastings Center Report 14:24-26. 1984.

Mettanando, Bhikkhu. “Buddhist Ethics in the Practice ofMedicine,” in Buddhist Ethics and Modern Society: An
International Symposium, ed.C.Wei-hsun Fu and S.A.
Wawrytko, New York, etc: Greenwood Press, 195-213.
_________________. “A Buddhist Model for Health Care
Reform,” www.mettanando.com
Nakasone, R.Y. Ethics of Enlightenment. Fremont, Ca:
Dharma Cloud Publishers. 1990.
Olson, Isaac. Fringe Medical Practices in Thailand.
www.thailawforum.com 2 December 2010.
Fujiki, N. and Macer, Darryl R.J. Bioethics in Asia. Eubios
Ethics Institute http://www.eubios.info/ASIAE/BIAE98.htm
Ratanakul, Pinit. Chaicharoen, Pitak. Letting-Go or Killing:Thai Buddhist Perspectives on Euthanasia. Eubio Journalof Asian and International Bioethics 8 (1998) 37-40.
http://www.eubios.info/EJ82/ej82c.htm
Ratanakul, Pinit. Bioethics in Thailand: An Update. Asian
Bioethics
Review
V.1
Issue
1,
March
2009.
http://muse.jhu.edu/login?auth=0&type=summary&url=/journ...
Ratanakul, Pinit. Bioethics and AIDS in Thailand: A Buddhist
Perspective http://www.vimokkha.com/bioethics.htm
CFL Blog Project: Legality of Euthanasia in Thailand
http://aaishabreuer.blogspot.com/2011/08/legality-ofeuthanasia...
Saniotis, Arthur. Changing ethics in medical practice: a Thai
perspective. Indian J Med Ethics. 2007; 3: 24-5.
Euthanasia
inThailand.
ThailandLaw
http://www.thailandlaw.org/euthanasia-in-thailand.html 17
Oct. 2013.
(This paper was presented at KBRT7)

A Buddhist perspective on
genetic enhancement- Ananya Tritipthumrongchok
General Manager, Eubios Ethics Institute, Bangkok, Thailand
Email: ananya@eubios.info
www.eubios.info

What is enhancement?
Human enhancement has emerged in recent years
as a blossoming topic in applied ethics. With continuing
advances in science and technology, people are
beginning to realize that some of the basic parametersof the human condition might be changed in the future.
One important way in which the human condition could
be changed is through the enhancement of basic
human capacities.
Human genetics has evolved to a level where wehave been able to manipulate the genetic constitutionof an embryo to a certain extent through genetic
engineering. The knowledge of human genetics has led
us to be able to enhance the positive traits in humans
while removing the negative ones. The various
interesting aspects of human genetics have unfolded
the mysteries of the physical and psychologicalcharacteristics of humans and opened doors to thebetterment of human life. The boundary between"good" and "bad” human genetic engineering depends
on whether or not the embryo is considered to be"animate".

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

The ethical problem of surplus pre-embryos
The fate of the other fertilized ova is an ethicalproblem, since they will soon become "sentient
beings”, if not already. But, we hear different views
from different Buddhist teachers. In the end, your own
motivations are one of the main deciding factors for the
morality of actions. A general principle is, it is better tobe aware of the problem and admit that your actions
are not completely pure, than pushing the problem
aside and defending all your actions even to yourself. If
you develop compassion and make prayers for the
beings you “have” to kill (the worms you kill if you growvegetables or build houses, the parasites you kill tohelp your child or pet, and so on) you will diminish thenegative karmic effects from killing those beings. Using
the awareness developed in meditation it is possible tohave a fuller understanding of oneself, other people,
and of life itself. Buddhists do not seek to ‘evangelize’or coerce other people to adopt their religion, but they
do seek to make its teachings available to whoever isinterested, and people are free to take.
In view of Buddhist teachings on rebirth, the sentient
being is counted from moment of conception (themeeting of three things: the sperm from the father, theovum from the mother, and the subtle consciousness
that is a continuum continuing from a preceding life).
Buddhist ethics are all about trying to help others andespecially trying to not harm them. The greatest harm
is of course killing someone. When discussing fertility
treatments, abortion, stem cell research. Generally,
Buddhism doesn't clearly state that "you must" or"you're not allowed to" this or that. Instead it explains
the functions of cause and effect also in psychologicaland moral matters, which is called the "law of karma".
The teachings tell you what the consequences are if
you harm or take the life of another sentient beings,
and then it's up to you if you want to take theconsequences or not, and if the good outweighs thebad.
In general, fertility treatment is a positive thing from a
Buddhist point of view, since you are encouraged touse all the techniques you have on hand (spiritual
practice, common sense, science, modern technology,
and so on) to help sentient beings. One problem iswhen you fertilize several ova, and then only use oneof them; we freeze the others – maybe one day todiscard.
Buddhism in Thailand
Nowadays, Western visitors to Thailand havedisplayed an increasing interest in our national religion.
Buddhism asks “Who was the Buddha?”, “What did heteach”, “What do Buddhists believe about life after
death, good and evil, and the beginning of the world?”
Let us consider these in the context of what a good life,“eubios”, should mean. The word “Eubios” was coinedin 1990 from the Greek Eu=good; Bios=life, to mean
27
"good life".
Buddhism sees life as a process of constant change,
and its practices aim to take advantage of this fact. It
27

Macer, DRJ. Shaping Genes. Eubios Ethics Institute 1990.

means that one can change for the better. The decisive
factor in changing oneself is the mind, and Buddhism
has developed many methods for working on the mind.
Most importantly, Buddhists practice meditation, which
is a way of developing more positive states of mind thatare characterized by calm, concentration, awareness,and emotions such as friendliness. Buddhism is a wayof life based on the training of the mind. Its one
ultimate aim is to show the way to complete liberationfrom suffering by the attainment of the Unconditioned,a state beyond the range of the normal untrained mind.
Its immediate aim is to strike at the roots of suffering ineveryday life.
All human activity is directed, either immediately or
remotely, towards the attainment of happiness in someform or other; or, to express the same thing in negative
terms, all human activity is directed towards liberationfrom some kind of unsatisfactoriness or dissatisfaction.
Dissatisfaction, then, can be regarded as the starting
point in human activity, with happiness as its ultimate
goal.
Dissatisfaction, the starting point in human activity, isalso the starting point in Buddhism; and this point isexpressed in the formula of the four noble truths of
Buddhism which set out the fact of dissatisfaction, its
cause, its cure, and the method of its cure.
The Buddha’s teachings can be understood on two
distinct levels. One is logical and conceptual and isconcerned with an intellectual comprehension ofhumankind and the external universe. It is on this levelthat the above questions are more easily answered.
The second level is empirical, experiential andpsychological. It concerns the ever-present andinescapable
phenomenaofeverydayhuman
experience, love and hate, fear and sorrow, pride andpassion, frustration and elation. And most important, it
explains the origins of such states of mind andprescribes the means for cultivating those states which
are rewarding and wholesome, and diminishing thosewhich are unsatisfactory and unwholesome. It was tothis second level that the Buddha gave greater
emphasis and importance.
Karma is a word that most everyone has heard of,but few people know the true meaning. It’s often
mistakenly thought of as a punishment and reward
system, and is used as a curse on those who do bad
things. “You’d better watch out for Karma!” as if it’s avoodoo police force of the universe. Karma is mostimportantly, understanding. It is neither good nor bad,just whole. If a person does good deeds, helps others,
and lives an honest life, they can still get “bad karma.”
If that person does all those things, but then judges
others who they say they are evil, then they will soon
find themselves on the opposite side of that fence.
By judging someone negatively, one is actually
asking the Universe for the understanding that madethat person behave that way. Common examples are intraits that are misunderstood. If a person says anotheris too controlling, then pretty soon, they will be accusedof the same. They may not even notice, because tothem, they were only being helpful, or looking out forsomeone, but most certainly not being controlling! Only

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

after the karmic shoe is on the other foot do they gain
the insight as to why the person they judged seemed tobe acting in a controlling way
There are different kinds of love, and terse arevariously expressed as family love, sensual love,emotional love, sexual love, selfish love, selfless love,
and universal love. If people develop only their carnalor selfish love towards each other, that type of lovecannot last long. In a true love relationship, one should
not ask how much one can get, but how much one cangive. It is not easy to live life sometimes, and face theworld with a smile when you are crying inside. It takes
a lot of courage to reach down inside yourself, hold on
to that strength that’s still there, and know that
tomorrow is a new day with new possibilities. But if you
can hold on long enough to this, you will come out anew person. Stronger, with more understanding andwith a new pride in yourself from knowing that you
made it. Just because you fell apart doesn’t mean
you’re broken. Have Faith and never, ever give up. It
may appear that Karma is happening to us, as if someoutside force is causing good things or bad things tocome to us. However, it is really our own innerconditionings and processes that are leading us toexperience outer effects or consequences in relation to
our own actions.
One of the thorny and most difficult things wehumans are ever called upon to do is to respond to evil
with kindness, and to forgive the unforgivable. However
justified you may be, or however enormous the hurt, it
is always possible to forgive. Why teach children about
the penalties that life has to offer when you could justas easily teach them about the rewards? Fear based
education is negative and faith based education ispositive. Simply put, this means that whether we are
fearful or faithful, just what we expect to have happen
will. Our expectations create our realities, and throughour own choosing we create our character, and ourcharacter creates our destiny. Even though this is aneasy concept to state it is a hard concept tounderstand, internalize, and put into action.
True happiness can be broadly defined as a mindstate. The characteristics of a mind-state include a
sense of universality, continuity and endurance. The
mind-state we call true happiness is not temporary, nothit-and-miss; it is not grounded in purely sensualgratification; it does not deal in extremes. It is constantand all-pervasive, and above all it is that which can beborne with ease.
Rebirth with Karma, as there is no soul totransmigrate from one body to another, "Rebirth"
occurs when the karma created by a past life carries
over to another life. Most schools of Buddhism teachthat conception is the beginning of the process ofrebirth and does, therefore, mark the beginning of ahuman being's life. One way to explain rebirth is tothink of all existence as one big ocean. An individual isa phenomenon of existence in the same way a wave isa phenomenon of ocean. A wave begins, moves
across the surface of the water and then dissipates.
While it exists, a wave is distinct from ocean yet isnever separate from ocean. In the same way, thatwhich is reborn is not the same person, yet is notseparate from the same person.
Turning our attention to the modern world, it is notdifficult to identify the psychopath who lacks any
measure of conscience and empathy—a person whom
we might characterize as being “cold and calculating”.
One troubling aspect of a psychopath is that they seemto be quite sane. But in reality they are anything but
sane. They have an insatiable appetite to be inpositions of power in order to control others andpsychically harm them. Virtually, every hierarchicalsystem is riddled with psychopaths. Probably, the firstrecorded evidence of psychopathic came at the
beginning of the 19th century.
How the psychopath gains power over those with aconscience is perhaps more disturbing? One of themost troubling of modern ironies is that those who
believe they have a conscience often permit
themselves to be undermined and ruled bypsychopaths who have no conscience. This, it could beargued, is the main cause of every form of modern
injustice and abuse culminating in the holocaust during
the Second World War.
From a Buddhist perspective, those who believe
they have a conscience might be slowly andimperceptibly transforming into subconscious, that is,
psychopaths. They are like someone driving thegetaway car for a gangster who, while never actuallycommitting the bank robbery, was nevertheless animportant element in the success of the robbery.
Everything that we see, hear, smell, taste, touch,
feel, think, remember, and imagine has a cause. If weare in physical pain, that pain has been caused bysomething; if we are mentally upset, then that mental
pain has a cause.
The law of Karma cannot be negated. There is noeffect that is not subject to the law of Karma. Just as
no negative effect can be brought about without acause, similarly no positive effect can be brought about
without a cause. Positive and negative thoughts,
feelings, sensations, experiences, and so on and soforth, do not occur in a vacuum. They originate at‘sometime’ and take place ‘somewhere’. In otherwords, they occur in time and space.
Applying Buddhism to Enhancement
Should we enhance life? Scientists tell us that life
started on this planet, somehow, about 4 billion years
ago, and since then life has expressed itself in many
diverse forms. But no one has observed the"beginning." We living beings are manifestations of an
unbroken process that has been going on for 4 billion
years. In that context we should consider
enhancement.
Positive Perceptions of enhancement
28
The International Bioethics Survey (Macer et al.)revealed very positive views of enhancement inThailand in 1993, which is illustrated in the three tables
below extracted from the paper. These were in28

http://www.eubios.info/Papers/HGT95.htm

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

response to the question: “Q28. How do you feel about
scientists changing the genetic makeup of human cells
to: ++ Strongly Approve + Somewhat Approve Somewhat Disapprove - - Strongly Disapprove DK
Don't know”. There are comparisons to the public in
New Zealand (NZ), Australia (A), Japan (J), India,
Thailand, Russia (R), Israel and to an earlier US
survey.

It is not surprising that so many Thai people undergocosmetic enhancement as discussed in the preceding
paper in EJAIB by Chutatip Umavijani (Nov. 2013).
Conclusions
If we have some condition should we stay in thatcondition and bear it – even at times suffering, orshould we try to improve ourselves by spending
money and using technology. We may spend ourmoney and time to work hard to study and takeeducation. A Buddhist perspective may be to take a
middle way, and have a thankful heart working hard forthe good of others. There could be more researchdone to examine why so many people in Thailand
appear to embrace enhancement using newtechnology, as we approach the genetic revolution.
Further Reading and References
The Designer Baby Debate: Should We Allow Genetic Engineeringof Babies in the US? by Charley Cameron, 02/19/13
http://inhabitat.com/the-designer-baby-debate-should-we-allowgenetic-engineering-of-babies-in-the-us/
Human Genetic Engineering http://whatsnew-riddhi.blogspot.com/2011/08/human-genetic-engineering.html
Reducing Karma and the Sources of Negative Actions, Speech, andThoughts
bySwami
Jnaneshvara
Bharati
http://www.swamij.com/karma.htm
Buddhism and Abortion : A Buddhist Perspective on the Abortion
Issue
By
BarbaraO'Brien
http://buddhism.about.com/od/basicbuddhistteachings/a/abortion.htm
Introduction to Buddhist Sexual Ethics: Having Sex with Someone
Else's Partner, Alexander Berzin Dorfgemeinschaft Bordo, Italy,
1995http://www.berzinarchives.com/web/en/archives/approaching_buddhism/world_today/introduction_buddhist_sexual_ethics.html
Karma and Rebirth By Barbara O'Brien
http://buddhism.about.com/od/karmaandrebirth/a/karmarebirth.htm
The psychopath and the Buddhist Icchantika http://www.energyen
hancement.org/The-psychopath-and-the-Buddhist-icchantika.htm
Buddhism: A Method of Mind Training by Leonard Bullen © 1994
http://www.accesstoinsight.org/lib/authors/bullen/bl042.html(This paper was presented at ABC14)

Jaron Lanier’s Lock-In as
Exemplified by Facebook- Jose Ma. Ernesto Jacinto Ybanez Tomacruz, Ph.D.
Philosophy Department, Ateneo De Davao University,
E. Jacinto Street, Davao City 8000, Philippines
Email: ybanez.tomacruz@gmail.com

In India and Thailand more than 50% of the 900+
total respondents in each country supported
enhancement of physical characters, intelligence, ormaking people more ethical. It could suggest several
things: that poor living standards and infectious
disease make people more pragmatic about"improvement", or that people in those countries havenot thought about the implications (even though they
were relatively highly educated samples). It isinteresting if this is a general trend in developing
countries, as it could have significant implications forinternational policy.

Abstract
Jaron Lanier, renowned computer scientist who iscredited to coin the term “virtual reality” (VR),empathically states that persons must beware of digital
lock-in. According to him “The brittle character ofmaturing computer programs can cause digital designs
to get frozen into place by a process called lock-in.
This happens when many software programs aredesigned to work with an existing one. The process ofsignificantly changing software in a situation in which a
lot of other software is dependent on it is the hardest
thing to do. So it almost never happens.” Thus, Lanieralso contends that “lock-in… is an absolute tyrant in
the digital world.” This paper contends that the203

Eubios Journal of Asian and International Bioethics 23 (November 2013)

ubiquitous, and also seemingly indispensable,
Facebook, has locked-in its users. From its creation in2004 by Harvard sophomore Mark Zuckerberg,
Facebook has become a monolith with a global 1.2billion-plus strong (and still growing) members atpresent. A monolith, which, has been showing signs
that it is becoming a runaway “absolute tyrant in thedigital world.”
Keywords: Digital lock-in, Facebook, data mining,
digital tyranny
The Beginnings and Evolution of Facebook
Facebook was created in February 4 2004 by Mark
Zuckerberg, a Harvard University sophomore, under
the name “Thefacebook.com”. In 2005, having
purchased the domain name for US$200,000, “The”
was dropped, and “facebook.com” became the official
29
domain name of Facebook.
“Facebook” originally referred to the publications thatsome colleges in Harvard give out to students at
beginning of the year to help students know each otherbetter. Zuckerberg designed his electronic version ofFacebook still with the same aim, however Harvard
students access them via the net. Initially, exclusively
for Harvard students, but in matter of months becameso popular, that the next year, 2005, was offered tohigh school students, and offered to general public in
2006. The trajectory of Facebook use was indeed
astounding. On its first launch in 4 February 2004,
there were “somewhere between twelve hundred andfifteen hundred registrants." By August 26, 2008
(around 4 years and 6 months from its 2004
launching), Facebook had its 100 million active users(An "active user" is defined by Facebook as a user who
has visited the website in the last 30 days). By April 8,
2009, Facebook already hit 200 million active users; bySeptember 15, 2009 already 300 million; by February 5
2010, up to 400 million; by July 21, 2010 already half abillion active users; January 5, 2011 already 600
million; May 30 2011 already 700 million; September
22, 2011 already reached 800 million; April 24, 2012,
up to 900 million active users; October 4, 2012,reached its 1 billion users; by March 31, 2013, already1.1 billion. Of course, according to David Cohen, even
Facebook that the said numbers may also even include
invalid accounts (duplicates 5%; improperly classified
30
1.3%; fake .9%) , but that still leaves us at least 1
billion active users of Facebook. Given such number,it’s worth noting that the population of Facebook’s
active users is only exceeded in the world by the31national populations of China (1,360,940,000) , andIndia (1,236,160,000). The United States is a distantfourth with its population of 317,22,000, and such
figures are as of 08 November 2013.
Digital Lock-in According to Jaron LanierJaron Lanier, renowned computer scientist who iscredited to coin the term “virtual reality” (VR), also
29
30
31

http://en.wikipedia.org/wiki/History_of_Facebook
http://allfacebook.com/form-10q-invalid-accounts_b122538
http://en.wikipedia.org/wiki/List_of_countries_by_population

nominated in TIME magazine as among the 100 most32
influential people , and recognized by Encyclopedia
33
Britannica as one of history’s 300 greatest inventors ,empathically speaks that persons must beware ofdigital lock-in. According to him: “The fateful, unnerving
aspect of information technology is that a particular
design will occasionally happen to fill a niche and, once
implemented, turn out to be unalterable. It becomes apermanent fixture from then on, even though a better
design might just as well have taken its place before
the moment of entrenchment…(p.8) The brittle
character of maturing computer programs can cause
digital designs to get frozen into place by a process
called lock-in. This happens when many software
programs are designed to work with an existing one.
The process of significantly changing software in asituation in which a lot of other software is dependent
on it is the hardest thing to do. So it almost never
happens. (p. 7)”
And according to Lanier such entrenchment isfurther cemented by the computers’ power to grow34
exponentially as essayed by the Moore’s law .
“Computers have gotten millions of times more
powerful, and immensely more common and moreconnected. It’s as if you kneel to plant a seed of a tree
and it grows so fast that it swallows your whole village
35
before you can even rise to your feet.” Thus, Laniercontends that “lock-in… is an absolute tyrant in thedigital world.”
The Facebook, since its inception, as the numbers
above show, have also exponentially grown, similarly
along the lines of the Moore’s law. So much so, that
contrary to Lanier’s view that Facebook, though “withcommercial intent, but without, as of this time of writing,36
commercial achievement,” Facebook eventually had
filed for its IPO (initial pubic offering) on February 1,
2012. The IPO gained Facebook US$16 billion. Around18 months later, as of August 2013, according to Brian
37
Womack , Facebook is worth at least US$100B. And
the profitability of Facebook is still expanding. In thesame article, Womack further states that: “The market
is gaining confidence that Facebook is going to be a
viable profit-generating machine in the future,” said
Laurence Balter, an analyst at Oracle Investment
Research in Fox Island, Washington. “People are32

http://en.wikipedia.org/wiki/Jaron_Lanier
Jason Lanier, “You Are Not a Gadget: A Manifesto,” Allen
Lane – Penguin Group, Penguin Books, Ltd. 80 Strand,
London W C 2 R ORI, England, 2010, Preface
34
Moore's law is the observation that, over the history ofcomputing hardware, the number of transistors on integrated
circuits doubles approximately every two years. The law isnamed after Intel co-founder Gordon E. Moore, who
described the trend in his 1965 paper.[1][2][3] His prediction
has proven to be accurate, in part because the law is now
used in the semiconductor industry to guide long-termplanning and to set targets for research and development.[4]http://en.wikipedia.org/wiki/Moore's_law
35
Lanier, p. 8
36
Lanier, p.16
37
http://www.bloomberg.com/news/2013-08-26/facebookmarket-value-tops-100-billion-amid-mobile-ad-push.html
33

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Eubios Journal of Asian and International Bioethics 23 (November 2013)checking their Facebook page more and more all thetime.”The Facebook Lock-in
As stated above by Lanier, Facebook, from its
genesis, was intended by Zuckerberg primarily as aprofit-making venture, a commercial entity. To keepsuch commercial edge, Facebook thus has to install its
own version of lock-in, which: “…once implemented,
turn out to be unalterable. It becomes a permanent
fixture from then on, even though a better design mightjust as well have taken its place before the moment of38
entrenchment. … Every element in the system –every
computer, every person, every bit- comes to dependon relentlessly detailed adherence to a common
39
standard, a common point of exchange.”
And such lock-in-ness is fundamentally embeddedinFacebook’s“StatementofRightsandResponsibilities.” Meaning, that, as in any digitalprogram or application, one can only have access tosuch program or application if first of all one clicks“Agree” to the said terms and conditions, or “Rights
and Responsibilities.” And such is categoricallyessayed as a provision says: “This Statement of Rights
and Responsibilities ("Statement," "Terms," or "SRR")
derives from the Facebook Principles, and is our termsof service that governs our relationship with users andothers who interact with Facebook. By using or
40
accessing Facebook, you agree to this Statement…”
Then such categorical statement is followed by ashort, but a motherlode provision: “Privacy Yourprivacy is very important to us. We designed our Data
Use Policy to make important disclosures about how
you can use Facebook to share with others and how
we collect and can use your content and information.
We encourage you to read the Data Use Policy, and touse it to help you make informed decisions.”
We say motherlode, because this provision
captures the essence of the lock-in-ness of Facebook.
“Your privacy is very important to us,” makes a blanket
statement decidedly meant to assuage a very basic
concern of any internet user: privacy. With such astatement, thus Facebook gives a putative (if not atleast implicit) assurance to its users that their very
fundamental rights and concern to privacy is being
warranted by Facebook. That is, if the statement istaken univocally, meaning, that the said provision is to
be interpreted in only one and the same way, which isindeed, because privacy is important for the users, thus
Facebook assures the users that their privacy will beappropriately protected by Facebook. However, this“Your privacy is very important to us” provision may
also be looked from another angle, or that it may also
be taken analogously. That is, as the phrase stands, it
can actually also be taken to mean another thing,depending on one’s vantage point, in this instance,skewed towards Facebook. Meaning that whatever it isthat a user holds important because it’s private, is also

held important by Facebook, for the simple reason that
because of the private matters that its users bring into
Facebook, Facebook is able to generate revenue from.
And that’s the reason why, the next sentence
makes clear sense, again advantageous to Facebook
when it says “We designed our Data Use Policy tomake important disclosures about how you can use
Facebook to share with others and how we collect and
can use your content and information.” The word
“designed” clearly essays that from the time one
becomes a user of Facebook, whatever one brings into
Facebook will only be according to such “design,” thus,
locked-in to the will and decisions of Facebook. Thus,
from the very outset, Facebook is indeed proving itself
to be totalitarian, absolutist.
Such totalitarianism has actually also foundexpression by way of the work of the philosopher
Emmanuel Levinas, especially on his thoughts about
the egoistic “self,” or the “I” as he calls it. The “I,” or Il ya, as expounded by Emmanuel Levinas, literally is, “il”,
meaning “it”, “y” meaning “there”, and “a” meaning“has”. Crudely further put, “it has there”. Correctly put, il
y a, is the there is, the verb “to be” of Being. In otherwords, referring to the existence of that which exists,
and not to that which exists itself. The il y a is akin, if
not derivative of Martin Heidegger’s Dasein, the therebeing. The notion of the il y a is significant because for
Levinas this is the grounding of all beings, of anythingthat exists. Meaning, anything which exists cannot but
exist. It has to exist for it to be an existent. There is thepersistence of the Being (act of existence) of a being or
beings (the one/s existing), or the insistence of the verbof the noun. This there-being of existence, at the first
instance however, is impersonal, or that the notion of
the term Being is impersonal. Thus Levinas says that,“Being is essentially alien and strikes against us. We
undergo its suffocating presence like the night, but it
41
does not respond to us.” It is not that there is nothing
there, but rather that what is there is some kind of avoid, or maybe an amorphous entity, akin to being
something which is there which is anonymous part ofthe landscape. However, amorphous being/s may be,it/they still cannot but persist in its/their Being. And thismode of existence is also taken on by the “I”, the “self”,
the “ego” the human being.
The human being, or the “I” or the “self”, is one of
the beings which has Being, or which exists. And justlike any existent, it would also like to persist in its
Being: “For man is able to take up an attitude withregard to his very existence. Already in what is called
the struggle for life, over and beyond the things
capable of satisfying our needs which that struggle
intends to acquire, there is the objective of existence
itself, bare existence, the possibility of pure and simple
existence becoming an objective... But the notion of
the struggle for existence is not enough to grasp therelationship of an existent with its existence as deeply
as we would like. When taken at the level of the time ofthe economic order, as it ordinarily is envisaged, it

38

Lanier, p. 16
Ibid., p.15
40
(https://www.facebook.com/policies/)
39

41

Emmanuel Levinas, Alfonso Lingis (trans.) Existence andExistents, (The Hague: Martinus Nijhoff, 1978), p. 23.

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

appears as a struggle for a future, as the care that abeing takes for its endurance and conservation. It is a
struggle for an already existent being for the
prolongation of its existence. It is not a continual birth,understood as a distinct operation by which an existenttakes over its existence, apart from what it may do to42conserve it.”This ontological persistence plus the impersonalityof the il y a thus makes for a highly self-seeking,egoistic, self-centered, human being, institutions, in ourcase, Facebook. This inflicting persistence of being is
also termed by Levinas as totality: “A being that has lifein the totality exists as a totality, lives as though it
occupied the center of being and were its source, as
though it drew everything from the here and now, inwhich it was nonetheless put or created. For it theforces that traverse it are already forces assumed; itexperiences them as already integrated into its needs
43
and enjoyment.”
If we notice, the said, totality or persistence in being
is a self-sufficiency that is not a total absence of needfor being or beings other than itself. As the above
citation says the forces other than “I” are “forces
assumed... integrated to its needs...” Its selfishness
consists in simply assimilating others, as if embracing
others in an octopoidal dance of death, simply for its
own purpose, for its own interest. Even the word
“interest”, etymologically dissected denotes such
egoism. “Inter,” meaning inside, interior, within; “est,”
is. Inter-est therefore refers to what is inside, meaning,that which is not found outside or does not go outside.
Meaning that in totality, everything goes back into the“I”, the “self”, and not to those other than itself. Ergo, in
totality, the human being, can be likened to the blackhole of physics. A black hole absorbs into itself
anything approximate it through its very strong
magnetic energy. The aforementioned persistence inbeing can be likened to the said magnetic energy of theblackhole, and as physicists would surmise, nothing
escapes a blackhole, and so nothing will also beallowed by the totalizing self to slip from its self-serving
grasps. Ergo, it is because of such totalistic propensitythat therefore, there is that aforementioned state of war
or violence among human beings, a war that therefore
casts somekind of a darkness between human beings:“The state of war suspends morality; it divests the
eternal institutions and obligations of their eternity andrescinds ad interim the unconditional imperatives... Inadvance its shadow falls over the actions of men. War
is not only one of the ordeals -the greatest- of which44
morality lives; it renders morality derisory. We do not
42

Ibid., pp 23-24.
Emmanuel Levinas, Collected Philosophical Papers,
Alfonso Lingis trans., (Boston: Martinus Nijhoff Publishers,
1987), p.25.
44
This is the other term which Levinas uses for ethics, whichon author says is “a metaphysical responsibility, an
exorbitant and infinite responsibility for other human beings,
to care not for being, for the unravelling of its plot, but forwhat is beyond and against being, the alterity of the otherperson.” Emmanuel Levinas, Ethics and Infinity(Conversations with Philippe Nemo), Richard Cohen
43

need obscure fragments of Heraclitus to prove thatbeing reveals itself as war... that war does not only
affect it as the most patent act, but as the very
patency, or the truth, of the real. In war reality rends
the words and images that dissimulate it, to obtrude in
its nudity and in its harshness. Harsh reality (thissounds like a pleonasm!), harsh object-lesson, at thevery moment of its fulguration when the drapings of theillusion burn, war is produced as the pure experienceof pure being. The ontological event that takes form inthis black light is casting into movement of beings
hitherto anchored in their identity, a mobilization ofabsolutes, by an objective order from which there is no
escape. The trial by force is the test of the real. But
violence does not consist so much in injuring andannihilating persons as in interrupting their continuity
making them play roles in which they no longer
recognize themselves, making them betray not only
commitments but their own substance, making themcarry out actions that will destroy very possibility for45
action.”Levinas also states that such natural proclivity tototality, the “self’s” absorption of the other, can haveseveral expressions. And one of them is in labor, or as
Levinas would say, the transformation of matter or theelements by man. According to the Pentateuch,
Yahweh created man in his image and likeness.
According to Levinas, the “self”, also transforms theworld or elements in his image or likeness. The
material world, or the “elemental” as Levinas calls it, isthere for the my taking, for my mastery.
The elements remain at the disposal of the I -to takeor to leave. Labor will henceforth draw things from theelements and thus discover the world... This primordial
grasp, this emprise of labor... arouses things and46
transform nature into a world...
I get myself a lump of clay. I knead it, I mold it, I
shape it according whatever shape I want it to have,then I put into the furnace, then taking it out of thefurnace, and after letting it cool, I paint it. As finishing
touch, as if not yet satisfied, I either stamp my insignia
on it or manually put my signature on it. The “I”
therefore simply makes that piece of clay a copy of the“I”, an imago, thus the other still becomes me. Thus, if
applied to Facebook, everything, and anything that isin, and transpires in Facebooks, is in and transpires in
Facebook, according to the “image and likeness” ofFacebook
Through labor, the “ego” or “I” does not onlytransform matter or the world. It also takes possessionof the world. Thus it can be noted, that one says “Thisis house is the fruit of my labor,” “This piece of special
paper used to be just a lump of grass was made byme,” and so on and so forth. We identify ourselves with
our labor, with our transforming of matter, and by sodoing we also end up appropriating the fruits of ourlabor. “This finished product is mine because I madetrans., (Pittsburgh, Pennsylvania: Duquesne
Press, 1985), p.3.
45
Levinas, Totality and Infinity, ibid.
46
Levinas, Totality and Infinity, pp.156-157.

University

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

it.” Again, the “I” simply agglomerates the other into thesame. And how more can Facebook manifest suchproprietary totality than by its being out and out profitoriented.
For such lock-in-ness or totality, to date, therefore
Facebook is at the very least known of the following
47
problematics according to Rosa Golijan : “Facebook
collects more data than you may imagine. For
example, did you know that Facebook gets a report
every time you visit a site with a Facebook “Like”
button, even if you never click the button, are not a
Facebook user, or are not logged in?
Your data is shared more widely than you may
wish. Even if you have restricted your information to be
seen by friends only, a friend who is using a Facebook
app could allow your data to be transferred to a third
party without your knowledge.
Legal protections are spotty. U.S. online privacy
laws are weaker than those of Europe and much of theworld, so you have few federal rights to see andcontrol mostof
theinformationthatsocialnetworks collect about you.
And problems are on the rise. Eleven percent ofhouseholds using Facebook said they had trouble lastyear, ranging from someone using their log-in without
permission to being harassed or threatened. That
projects to 7 million households — 30 percent morethan last year.”
However, Levinas himself also prescribes that the
Other can actually resist the totalizing proclivities of theegoistic “I”, i.e., the “ego”, comes to be aware thatthough he usually is able to assimilate other beings,
and there also are some which sometimes resist suchassimilation, there really is that other which totally or
absolutely defies his totalistic predilection. That there
has been so many things of this world that he has
enjoyed, has appropriated, provided him nourishment,
been made into his image and likeness, yet there isthat something which it cannot and will not allow it so.
And during such moments of resistance, of defiancethat the Levinasian moment of ethics -the epiphany of
the Face or the Other- happens.
The ethical moment, the moment in which the“ought” shows itself, is found, for Levinas, on the levelof sensibility when the egoist self comes acrosssomething that it wants to enjoy, something that it
wants to make part of itself, but cannot. That which theself wants to enjoy but cannot is the other person. The
reason that it cannot enjoy the other person is … in theother person who pushes back, as it were, who does
not allow himself to be consumed in the egoism of myenjoyment. The presence of the other, on this level, is
48
not, properly speaking, known.
Thus, though locked-in, a Facebook user can also
have still reasonably choose to remain within thedomains of Facebook as it also has its attendantadvantages. Among the most salient being that as asocial networking tool, it capacitates one linking withpeople. Facebook has also become a democratic
platform for individuals or groups to express their ideas
whether it be in politics, science, technology,
commerce, economics, and anything and everything as
long as they are acceptable according to the locked-in
design of the Facebook. For all its problematics, thisauthor can’t help but praise Facebook for having beena fast and ubiquitous or accessible gateway of
information, specially for emergencies, as in disasters,
calamities, etc. Messages seeking help, sympathy, aid,
can easily reach multitudes of Facebook netizens at adigital speed. Thus, it can be deemed that the following
can also be observed by Facebook users so as tominimize the totalizing impact of Facebook’s lock-in, of49
course, in a very digital manner :Think before you type. Even if you delete an
account (which takesFacebook about a month), some
info can remain in Facebook’s computers for up to 90
days.
Regularly check your exposure. Each month,check out how your page looks to others.
Review individual privacy settings if necessary.
Protect basic information. Set the audience for profile
items, such as your town or employer. And
remember: Sharing info with “friends of friends” could
expose it to tens of thousands.
Know what you can’t protect. Your name andprofile picture are public. To protect your identity, don’t
use a photo or use one that doesn’t show your face.
“UnPublic” your wall. Set the audience for all
previous wall posts to just friends.
Turn off Tag Suggest. If you’d rather not have
Facebook automatically recognize your face in photos,
disable that feature in your privacy settings. The
information will be deleted.
Block apps and sites that snoop. Unless you
intercede, friends can share personal information about
you with apps. To block that, use controls to limit theinfo apps can see.
Keep wall posts from friends. You don’t have toshare every wall post with every friend. You can also
keep certain people from viewing specific items in yourprofile.
When all else fails, deactivate. When you
deactivate your account, Facebook retains your profile
data, but the account is made temporarily inaccessible.
Deleting an account, on the other hand, makes
it inaccessible to you forever.
To end, let me once again quote Jaron Lanier: “Wehave to think about the digital layers we are laying
down now in order to benefit future generations. We
should be optimistic that civilization will survive thischallenging century, and put some effort into creating
the best possible world for those who will inherit our
50
efforts.”47

http://www.nbcnews.com/technology/consumer-reportsfacebook-privacy-problems-are-rise-749990
48
Anthony F. Beavers, Introducing Levinas toUndergraduate Philosophers (http://cedar.evansville.edu/~tb2/trip/levinas_intro.htm, 23 March 2001), p.2

49

http://www.nbcnews.com/technology/consumer-reportsfacebook-privacy-problems-are-rise-749990
50
Lanier, p. 20

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

NOTE. I offer this humble paper in memory of myfellow Filipinos who perished and are still suffering due
to the onslaught of the typhoon Haiyan/Yolanda. I alsooffer this as a salute to everyone (Filipinos and nonFilipinos) who unselfishly extended themselves to ourcountry in this time of direst need. I know, together,with God’s grace, we shall prevail. [Ed.- Readers may
be interested to join the Eubios Youth Looking
Beyond Disaster (LBD) programme, with the LBD4
occurring in the Philippines, 2-6 April 2014. See thewebsite of Facebook pages!!]

Framework for Advancing
Health Care in Pakistan- Sumaira Khowaja-Punjwani, Master of Bio-Ethics, BScN
Faculty of Health Science, The Aga Khan University,
Stadium Road, PO Box 3500, Karachi-74800, Pakistan.
& Fogarty International Centre, NIH USA
Email: sumaira.khowaja@yahoo.com

Abstract
Health inequity is prevalent in developing countries
and despite of showing success in terms of national
averages health attainment in developing countries has
not reached up to the mark of desired outcome.
Patterns of these inequities can be seen in our country
and society in both the directions i.e. horizontal andvertical. Inequity in the domain of health is vital as it isconsidered as a significant factor for human life anddevelopment. Moreover, these inequities in health leadto other inequities prevalent in our society that
contributes again in health inequity. Therefore it can besaid that inequities in health are the consequences ofvarious factors i.e. Individual factor, social inequities,
economical inequities, cultural value and beliefs,
environmental conditions, system factors anddiscriminatory beliefs. In order, to overcome theseinequities ‘health equity’ is a perfect approach toaddress.
In this paper a framework for advancing health equity
is discussed. In part I of this paper an attempt would bemade to understand health inequity and factors that
contribute and precipitate. In part II, solutions andrecommendations will be proposed and discussed thatwill be effective for developing health equity in ourcountry. This part will focus two areas i.e.
understanding health system governance matrix ofPakistan, its strengths and weaknesses at central and
Ministry Of Health (MOH) policy level; secondly,
promotion of public health and human rights inPakistan.
Key Words: Health equity, disparity, social justice
1. Understanding disparities
It’s been more than 60 years, since that Pakistan has
got independence and citizens are enjoying thefreedom of being independent nation. Many years havebeen passed since Pakistan got affiliation with humanrights bill. However, the pattern which is very evident inthis country is that the better-off is becoming better day
by day and the less well-off are being deprived fromtheir needs more with the passage of time. It isbecause that the better-off, more educated, more
powerful, and wealthier in society have much greater
capacity to improve their health than do the less welloff. This is the reason because of which the conditionof inequity is becoming persistent and a pattern ofresistance is becoming evident amongst them. Besides
human right bill affiliations, it doesn’t seems that thiscountry will be able to achieve Millennium
Development Goals (MDGs), in which the aim is to
reduce hunger and poverty, and to address various
issues is our society i.e. gender inequality, access to
education, access to health care, access to safe waterand safe environment. Thus, it can be said that thecondition of inequity is existent and is becoming
persistent in many developing countries also including
Pakistan. This pattern of these inequities can be seenin our country and in our society in both the directions
i.e. horizontal and vertical. I stated here inequities
prevalent in our country in horizontal and verticaldirections i.e. these inequities can be seen in every
spectrum of our society, for example, inequities
prevalent among men and women, urban and rural
areas, working class, social class, health, education,
income, working conditions, disabilities and death.
Although, the inequities or disparities that are
mentioned above are avoidable and are unnecessary.
2. Understanding health inequity
Health inequity can be defined as differences inhealth which are not only unnecessary and avoidable
but, in addition are considered unfair and unjust. Healthinequity is prevalent in developing countries ascomparative to developed countries and despite ofshowing success in terms of national averages healthattainment in developing countries is not up to the markor the desired outcome. Let us see this concept withthe help of an example of Pakistan’s infant mortality
rate (IMR). Pakistan is a country where life expectancy
is lowest and IMR is highest. Moreover, Maternal
Mortality ratio (MMR) is more than 500 per 100000 live
births. Almost 300 to 550 per 100000 women dieannually from child birth process. A point to ponder isthat those deaths are avoidable with the provision ofcertain facilities and by taking simple measures of
prevention but despite of this fact these deaths areprevalent and are rising day by day. These statistics
rings various questions in ones mind that why such
pattern is being observed in our country? Why it is not
avoidable? Does this pattern is related with the othercauses i.e. individual, social, cultural and etc?
Looking at the statistical analysis of health indicators
it can be said that amongst all the disparities, inequity
in the domain of health is vital as it is considered asignificant factor for human life and development.
Moreover, these inequities in health lead to otherinequities prevalent in our society that contributes
again in health inequity. Therefore it can be said that
inequities in health are the consequences of various
factors i.e. Individual factor, social inequities,

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

economical inequities, cultural value and beliefs,
environmental conditions, system factors anddiscriminatory beliefs. In order, to overcome theseinequities ‘health equity’ is a perfect approach to stopthese inequities.
3. Factors that contribute to Health Inequity
In this part an attempt will be made to highlight someof the factors that contribute or leads to health inequity.
Because framework to advance health equity can not
be discussed in isolation as it is related to other various
factors. In other words, it can be said that healthinequity is a result of interaction of multiple factors.
These factors can be categorized as individual factors,social inequities, economical inequities, cultural value
and beliefs, environmental factors, system factors anddiscriminatory beliefs.
Individual factors:
Individual factors effect directly on health andinfluence it. To say that there are inequities in healthand the responsible for these inequities is only system
is a wrong assumption and statement because
individual factors also contribute in inequities in thedomain of health. These factors include an individual’sage, genetics, health behaviours and chronic illnesses.
Social factors:
Other than individual factors, social factors also playa vital role in health inequity. Social factors are also
referred as Social Determinants of Health (SDH).
These social inequities are a life long process. I am
referring this as life long process because it starts fromthe day a person is born and continues through out life
in different domains, for example, education, work andetc. These social inequities exist in our society
because of the different classes that we have in oursociety as the people who are well to do can enjoy
every benefit that they can afford or buy, on thecontrary poor class only suffers and bears the burdenof diseases. Besides this, these social factors also
leads to lack of access to education, lack of access tohealth care facilities, race discrimination, classdiscrimination and gender inequity.
•
Education and Health:If we refer to lack of access to education and its
impact on health inequity then we observe globally auniform pattern i.e. the pattern of disparities in healthamong the people who are not very privileged to haveaccess to education as comparative to those who arewell educated because education is one of the factor
that plays a significant role in decreasing social
inequities because it creates awareness amongst thepeople and also provides way to live life effectively andproductively for oneself and for society. However, on
the other hand, if we see the system of education in
Pakistan then it can be said that it is one of theweakest system not in terms of its planning and paper
work but in terms of its actual field application andmonitoring. If we look facts and figures then it reveals
that the adult literacy rate of Pakistan is 49.9% which isvery low comparative to other developing countries aswell for example the literacy rate of our neighbour
country i.e. of India is 61%. The reason of stating thesestatistics here is just to highlight the difference which is
the result of the issue of priority setting in terms of
expenditure. In Pakistan, education is the domain
which gets low priority and hence less funds areallocated to this domain for expenditure. The data on
public expenditure on education reveals that Pakistan
gives low priority to education: it spends relatively lesson education, 2.3%, compared to other countries.
The statistics mentioned above provide the overall
global picture of the education and its impact on healthinequity, but if we see within our country then also
disparities exist amongst the provinces where the main
domain is urban and rural population difference. The
schooling system of rural and urban areas is also
distinct from each other. The facilities, environment andeducation provided in rural setting are different fromthe urban setting. The facilities that I am referring tohere are the facility of water, sanitation and many
more. These all eventually results in weakerperformance on equitable distribution of educational
opportunities.
The point of discussing these all facts here is thatthese inequities in health impact significantly on healthas it is directly related with income and employment
through which the cost of health care facilities can beafforded. In addition, educated people’s approach tolife and risk taking behaviours is different because of
the level of awareness that they possess. Moreover,people who are less or uneducated, work in the areas
which are highly risky to the health and life; forexample, workers of cement, cloth and cotton
industries are prone to develop respiratory tract
diseases, workers of mines and automobile workshops
are vulnerable to accidents and deaths, workers oftransport industries are prone to accidents, sexual
abuse and developing sexually transmitted diseases.
Let us understand this concept with the help of an
example, i.e. think about a person who belongs to lowsocio-economic class of our society and because ofwhich they are unable to get education. Later on, when
they grows up and starts their own family thendefinitely they have to earn income. Because theperson is uneducated, therefore they are unable to do
any such job that is limited to qualified persons andthey end up doing certain kinds of job that involve risks,
for instance, a driver, worker in a coal mine or cotton
industry or etc. Hence, education is the only means bywhich health status can be enhanced and uplifted.
•
Access to Health care:
Inequities in health care also exist because ofanother important social factor which is lack of accessto health care. In Pakistan, the setup of health careprovision is well formulated in terms of its paper work
but if we see the implementation of that system that
this body is non-functional. I would like to elaborate thisthing more in detail that the government system of
health care provision is well formulated in terms ofplanning the setup for example in urban areas theconcept of Primary Health Care Centres (PHC),
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Eubios Journal of Asian and International Bioethics 23 (November 2013)

Care (THC), and in rural areas the concept of Basic
Health Care Centres (BHU) and Rural Health care
Centres (RHC). However, if we refer to the availabilityof doctors or paramedical staff or the supplies thatthese setups should have then this becomes
questionable and this thing is because of the same
reason i.e. the issue of monitoring. Thus, if in a village
there is only a building of BHU or RHC but no doctor,
no paramedical staff and no or inadequate supplies
then how people can get benefit out of it. On the other
hand, the issue of affordability comes with Private
hospitals.
Consider a situation, if a person residing in a village
suffers from any disease that demands proper healthcare and he is brought to BHU or RHC then we canthink of that what he is going to get out of thisparalyzed system. As a result, he will be referred to
THC but the issues that surround this situation are theissue of access to health care, affordability of it andthen delay in the provision of health care which is
because of system failure.
Figure 1: Summary of some factors linked to inequity•
Gender and Health:
Gender discrimination and its impact on health is asignificant issue of women of Pakistan, which they facein their every day life and in every spectrum of it. The
women of Pakistan start facing these issues even
before they are born and it continues through out theirlife. It is their fate and a bitter reality to face thisdiscrimination from education to employment, fromdomestic violence to social injustice and etc. Although,in Pakistani parliament, the proportion of women
representation is higher as compared to some othercountries but the fact is that only some women enjoy
life and health at the highest level but on the other
hand other women are deprived of their basic rights.
The social system of Pakistan is structured in such a
way that restricts women from the equal right toeducation, access to health care, deprived of nutrition,lack of awareness of their rights and many more.
Because of this situation women are more vulnerable
to diseases, violence and every type of crime. They are
the ones who are prone to domestic violence, sexual
abuse, harassment, rape, injustice, forced marriages,
honour killing and etc. These all things not only affecttheir physiological health but also psychological,
mental and emotional health and well being.
•
Class Discrimination:
Class discrimination is the major determinant ofhealth inequity because the health care systemprovides same opportunity for every one. In Pakistan,
the class system is very evident, not only amongst
people it prevails amongst societies and communities
as well. In addition, the concept of the free market
economy has been diminished which is the result of thecapitalist. As in capitalist society, neither the oppressedpeople have control nor do they havechoice to use the resources. Moreover, therich people who are in position to afford
health and health care services are able to
do so while, on the other hand poor people
cannot even think about buying the basic
health care needs as it is out of theiraffordability. Therefore, while determining
any policy regarding health the concept ofhorizontal and vertical equity should beconsidered carefully i.e. equals should betreated equally and unequal should betreated unequally.
The social factors discussed in theabovementioned
paragraphs
affectsignificantly on the health equity and thisconcept of their interaction can also beeasily understood by the visual illustration in
Figure 1. From the illustration it is clear thatthe social factors affect directly healthequity and also affect other factors, in a two
way process that both the factors are
related and influenced by each other. Thus,
it can be said that unequal provision ofhealth facilities, unfair distribution of
resources and violation of human rights,
cause the outcomes which are unacceptable andunfair. Consequently, the people who are rich enjoy thebenefits and those who are poor bear the burden of
diseases and premature deaths. Suppose a scenario ofa young person who is suffering from any chronic
illness. Because he is not well therefore his ability towork is decreased and he is unable to earn as much as
he was able to earn previously when he was in his
good condition in terms of health. His low earning
capacity will definitely affect the economy of his family,
resulting in poverty, which will further lead him to illhealth. Because of his condition, his own as well as his

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

family life is affected. Thus, it is a vicious cycle which
can only be broken by implementing policies that
address health equity because if that person will be in
his good health then only the needs of the family canbe met. These inequalities are resulting in the poor
health and other health related problems. So it is theneed of the time to rethink about these determinants.
Economical inequities
After social factors, the other factor that affects
health is the economic factor. As mentioned above
these two factors have their own independentinteraction which is two way process.
•
Poverty and Health:
Income is the fundamental reason which is linked
with health care affordability in the absence of aformulized and functional system of health care bygovernment. The people, who are poor, are unable toavail the right to health look at it as luxury rather thanas necessity or right. These are the people who did not
get enough chance to be educated which leads them toget lesser chances for good income and secure jobs.
They are the people whose social life and social statusis also diminished so how they can think of health insuch a miserable condition. That’s the only reason to
say that poverty is the root cause of inequity in every
spectrum of life including the domain of health.
Moreover, inflation in the prices of every item makes
their condition more miserable. Consider the situationof a women residing in rural area that is dying because
her family is unable to afford the transportation charges
of a vehicle that can take her to a hospital where she
can have health care and her life can be saved.
Therefore, the main reason here is not in terms ofhealth care affordability but the issue starts from thetransportation expenses and so on. Also, the issue
comes here of inadequate nutrition because of poverty
that leads them to illnesses which are curable. Thus,
poverty is a significant factor that contributes in healthinequity.
Cultural factors:
Beside economic factors, cultural beliefs also play asignificant role in terms of health and health careaccessibility. These cultural beliefs and norms of aparticular community come from their ancestor and arepracticed as religion therefore, the practices which areformulated as a result of their cultural belief are unable
to change or even modify. Consider a community
having cultural norm not to visit a doctor when they are
ill rather to see a Hakeem. Just imagine that how manymothers are dying because of the births attended by
Traditional Birth Attendants (TBAs) whose skills arequestionable. These are the reason of having highmortality in our country.
Environment factors:
Communities with no education, no good job andpoor income in the end results in to living in anenvironment which have no good conditions in terms ofaccess to safe water, sanitation, safe neighbourhoodand etc. These poor people have to live in the areas

which are unclean and full of waste products that maketheir condition more miserable and make themvulnerable to the diseases which are caused byresiding in such an unhealthy environment.
Systems Factors:
The first system factor that affects health equity is of“Resource allocation”. The reason of health inequity is
not always resource allocation some times it is also theresult of poor resource allocation for example in termsof availability and allocating the number of doctors or
nurses per unit population, quality and types of medical
treatment available and etc. It has been found that theissue of proper resource allocation has been foundprevalent in the societies which have inequity in health.
In addition, the inequity result not only from theshortage of resources but the misuse of resources andthis is also the world wide reason that is leading to thepoor health. Pakistan spends less on health andeducation combined than on military. Less spending ofresources generates inequities in health, which affects
those people who are either poor or unable to accessto the healthcare institutes. Other than resource
allocation, health care system itself is another reason
leading to health inequity and details about it areprovided in the paragraph access to health of thispaper in detail.
Discriminatory factors:
Discriminatory factors are the beliefs that a
particular community have regarding a particular groupof people which marginalize that group of people fromrest of the population. These discriminatory factors
include immigration status, national origin, disability
and infectious diseases.
Up till now we have discussed in detail the factors
which lead to health inequities. These factors areindividual, social, economic, cultural, environment,
system and discriminatory. The above mentioned
illustration of these factors also provides the way thesefactors interact with each other.
After understanding the factors the next step is to
discuss the ways by which this problem can beovercome. Below is an attempt to address this issue of
health inequity.
4. Understanding Constitution and Law
For any country the constitution and law is ofgreater significance as it is a key factor by which agovernment run itself. Besides government, theconstitution is also needed by people for theirfundamental rights that include social, economic andcultural rights. It is very important for a nation to know
the countries constitution or law so that they can claim
and ask for their right. In the absence of this knowledge
right about it cannot be claimed. On the other hand,parliamentarians should have equal knowledge about
health equity and basic human rights.
Let us examine the above mentioned concept withthe help of an example i.e. the constitution of Pakistantalks about basic human right which is the right ofdignity of humans and prohibition of torture but if we211

Eubios Journal of Asian and International Bioethics 23 (November 2013)

see the actual existing system then the gap is foundbecause there is no such implication. We see police
torturing ordinary citizens for no reason but thequestion is who knows it and who is addressing it? In
addition, this is affecting an individual’s physical andmental health. So the key factor that can bridge thisgap is that the people of this nation should know theconstitution so that they are aware about their rights asa Pakistani citizens along with the responsibilities. Until
and unless people of this nation will not make an effort
to know their rights they can not exercise it and bringabout change. Therefore, it can be said that the
problem is with the implementation of the constitution
which can only be done by creating awarenessbecause the constitution was build by the people likeus. Referring to health and health care in ourconstitution things are written in black and white but
are not implemented the way it should be. Thus, tomake equity in health there should be efforts forhumans to have equal access and opportunity for theirhealth and health related issues
Understanding Health Policy:
Health policy is the means by which people’s
standard of living can be maintained. These policies
not only affect the health of an individual but also
affects significantly on employment, education, housing
and etc. Some of the important features that should be
kept under consideration while developing healthrelated policies are that it should be evidence based,focused on the desired outcome and most importantly
it should be beneficial for the people for whom thepolicy is being developed. Therefore, it should betargeted to improve overall quality of life of people, if a
policy is unable to do so then that policy should not bemade or should be modified according to the need ofpeople. In the following paragraph an attempt is madeto identify strengths and weaknesses of our current
health system governance.
•
Health system governance matrix ofPakistan; Strengths and weaknesses:
The strengths of Health system governance matrixof Pakistan at central level are that it promotes social
safety nets for the poor and vulnerable; and there isincrease in role of the media and NGO’s in protecting
people’s health. At the level of MOH policy, firstly, thepreparation of draft bills to update health legislation.
Secondly, there is rapid emergence in role of the
Pakistan health policy forum as a civil society
organization. Thirdly, stable turnover of healthpolicymakers during the last six years has been
observed which a positive element is. Fourthly,
increase in public private interaction has been
observed. And lastly, preventive programs, especially
the LHW Program which has a strong community as
well as equity dimension.
On the other hand some of the weaknesses with thehealth system governance matrix of Pakistan at centrallevel are that the lack of participatory decision making
and culture of accountability has been observed.
Parallel streams of bureaucracy and technocracy do
not seem to work in unison and adherence to rules andprocedures is considered as an end rather than as acontinuous process. Also, there is lack of consumer
protection act delays or deny justice. At the level of
MOH policy, firstly, short-term objectives were set
which override the need for focus on health outcomes.
Secondly, health equity is not high on the policy
agenda although it should be. Thirdly, mechanisms tomonitor transparency of decisions do not exist.
Fourthly, decisions are often tinged with personal
preferences, not evidence-based. Fifthly, legislation onminimum standards of care is absent with lax
regulation and enforcement capacity. Sixthly, policy,
planning, health information and surveillance units are
weak. Seventhly, there are delays in release andutilization of funds. Eighthly, accountability systems
focus on procedure instead of performance and lastly
and the most important that bioethics is not on thepolicy radar of MOH. At the level of policy
implementation some of the weaknesses are that there
is minimal protection against hazards from personal
health services. Also, gaps exist in policy and practicefor recruitment, posting and promotion of staff andrules favor seniority over meritocracy. Instruments forevaluation of staff performance are improperly used
and responsiveness of public sector health services is
not monitored. The important point is that thephysicians turned managers lack understanding ofadministrative matters while bureaucrats lack healthorientation. The most commonly practice observed inour context is that physicians and allied staff
extensively engage in private practice outside andoften within public institutions. Support systems
function inefficiently and code of ethics exists with theprofessional associations but not practiced.
Social Justice
After having looked at the constitution and policy’s
strength and weaknesses the other approach by which
health equity can be achieved is by enhancing social
justice. Because health equity is best thought of not asa social goal in and of itself, but as intrinsically
imbedded in a more general pursuit of social justice.
This social justice in healthcare can be achieved by
two means i.e. one by promoting health and secondly
by promoting human rights.
•
Health Promotion:
For promotion of health equity and to reduce social
inequalities in health, the first step is health promotion
and public health. Although, if we look at our healthsystem in terms of policy development that it can besaid that the policies are well formulated for school
health service, safe water and sanitation, familyplanning, control of communicable diseases and etc.
Moreover, the outcome of these policies is not justlimited to individual’s health but the actual goal behind
all these policies is to promote health equity by
reducing social inequalities in health and empoweringcommunities. However, the issue that comes here is at
the level of implantation and continuous monitoring forwhich adequate efforts were not made. This is the only
reason which is of great hindrance in promoting healthequity. If this gap is tackled skillfully then only health212

Eubios Journal of Asian and International Bioethics 23 (November 2013)

equity can be achieved.
•
Human Rights Promotion:
Many of the inequities in health sector can be
reduced by enhancement and promotion of humanright awareness. As health is vital to life and plays acentral role therefore, if an individual is healthy then
only he and his family can survive and make efforts fortheir production and growth. That is why it is said that
Health is Wealth. If we refer to the various declarations
on human rights then they addresses health as humanright. These declarations includes, Article 25 of
Universal Declaration of Human Rights, Articles 7, 11
and 12 of 1, Articles 10, 12 and 14 of Convention on
the Elimination of All Forms of Discrimination Against
Women, Article 5 of Convention on the Elimination of
All Forms of Racial Discrimination, and Article 24 ofConvention on the Rights of the Child. Moreover, theWHO constitution also mentions that “the enjoyment of
the highest attainable standard of health is one of thefundamental rights of every human being....” Thus, all
the declarations that refers to human right also states
health as one of the human right. However, on theother hand, in today’s world the arena of debate isshifted from the question that is health a human right?
To how much health care is human right? Before
determining any answer to above mentioned question,
I think first we should find out that what defines ormakes anything as right? Or what are the criteria forsaying anything as a “right”? For example, by whatcriteria it is determined that food, shelter and clothing
are right and why in that list health is not there? I thinkthat one criteria can be the difference of necessity andluxury. The thing that is defined as necessity makes itright and the one that comes under the domain ofluxury is not a right, rather it is a privilege. However, I
see two issues in this approach, first is the question
here comes that who makes demarcation between
necessity and luxury that will determine it as right or
privilege, i.e. Grand sez who? Secondly, the termnecessity and luxury can be different for different
people, society, culture, gender or etc. In addition, if
universal standard is being set then who sets thatstandard, for whom and how? Thus, the question
remains the same that what is right and what is not
right? Similarly, the question “is health a human right?”
remains same. But it cannot be neglected that humanrights are directly linked with health and provision ofhuman rights is considered as one important factor
leading to health equity.

access to health care for all humans without regard torace, creed, colour, religion, socio-economic status andetc. Which is in true terms the message of Islam
therefore should be followed by the Islamic Republic ofPakistan.

5. Conclusion
In a nutshell, it can be said that by only looking at theconstitution, policy and promotion of health, we canmove towards equity in health. But actually we have tothink and rethink about the factors that are leading tothese inequities in health as it is the root cause. If weare able to deal with these root causes then only equity
in health can be achieved. The concept is health equity
should not be limited to only provision of health but
also should address the other domains i.e. social
determinants of health. Beside this, state has also ahuge responsibility to promote universal and equitable

Few doubt the benefits of medical research; theadvances made in the twentieth century reduced
human suffering and extended lives. New techniques,
technologies, and pharmaceuticals have been so
successful that many people suffering from disease
believe that cures for their diseases are on the way ifthey can simply live long enough to benefit. The valueof research is so great that most people agree it isworth some risk of suffering or even death to reap thegreat benefits new treatments can produce. Millions ofanimals are sacrificed to medical research each year,
but large numbers of humans are also negatively

References(2007). Acheiving Health Equity: from root causes to fairoutcomes. Commission on Social determinats of Health.
(1978). Declaration Of Alma Ata. World Health Organization.
(1966). International Covenant on Civil and Political Rights.
(2009). National Education Policy: Ministry of Education
Government of Pakistan.
Barlow, Philip. “Health care is not a human right.” British
Medical Journal 319, no. 7205 (1999): 321.
Convention on Elimination of All Forms of Racial
Discrimination.
http://www2.ohchr.org/english/law/pdf/cerd.pdf (accessed
09 01, 2009).
Convention on the Elimination of All Forms of Discrimination
Against
Women.
http://www.hrcr.org/docs/CEDAW/cedaw.html(accessed
09 01, 2009).
Evans, T., Whitehead, M., Diderchsen, F., Bhuiya, A., &Writh, M. (2001). Challenging Inequities in health: From
Ethics to Action. NewYork: Oxford University Press.
Freire, P. (1993). Peadgogy of the Oppressed. Toronto:
Penguin books.
Health and Human rights: Governments' Obligations to
Ensuring
the
Human
Right
to
Health.
http://pdhre.org/rights/health.html (accessed 09 01, 2009).
International Covenant on Economic, Social and Cultural
Rights.
http://www.unesco.org/education/information/nfsunesco/pdf/SOCIAL_E.PDF (accessed 09 01, 2009).
Pokras, O. C., & Baquet, C. (2007). What is Health Disparity.
Ronis, K., & Nishtar, S. (2007). Community Health Promotion
In Pakistan: A Policy Development Prespective. IUHPE
Promotion & Education .
Sen, Amartya. “Why and how is health a human right?” The
Lancet 372, no. 9655 (December 2008): 2010-2013.
UN.
Universal
Declarationofhumanrights.
http://www.unhchr.ch/udhr (accessed 09 01, 2009).

Exploitation in Research:
Utilitarian Considerations- Randall Horton, Ph.D.
Adjunct Professor of Philosophy, San Jacinto College South,
13735 Beamer Road, Houston, Texas 77089
Email: Randall.Horton@sjcd.edu

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impacted by research, including some who lose theirlives.
While some individuals are willing to risk their healthfor the greater good of humanity, most individuals will
not expose themselves to great risk unless they feelthey will benefit from it in some way. Further, mostpeople will expose themselves to minimal risk with nopersonal medical benefit only when they arecompensated for time, effort, and inconvenience.
These two conditions create a dilemma forresearchers. In order to obtain research subjects,
researchers must either convince subjects that the
research is so beneficial to society that it is worth
risking the health of the subjects, or researchers must
offer sufficient enticements to encourage researchsubjects to participate. The third alternative is
unseemly—researchers might be tempted to coerce
research subjects in a variety of ways. Research canbe conducted on captive populations such as prisoners
or soldiers, or it can be conducted on vulnerable
populations such as those living in extreme poverty.
This paper attempts to determine when inducements
may or may not be coercive and dehumanizing. Most
guidelines for the protection of vulnerable populations
are written in Kantian, or at least deontological,
language. I will argue that a Utilitarian, or teleological,
framework is more consistent with the generallanguage of research ethics and offers a vigorous
method for evaluating the potential for exploitation anddehumanization in research. In particular, I am
interested in research involving those who are
extremely disadvantaged economically. Extreme
poverty in and of itself can be conceived of as a social
injustice. To exploit extreme poverty for the benefit of
the affluent would appear, on the face, to be an
outrageous injustice. Indeed, all ethical codes forresearch include protections for such vulnerable
populations. When someone’s life and health arethreatened by poverty and hunger, even minor
inducements can be coercive. Many people are in aposition that makes it impossible for them to reject any
offer that might bring them food or basic medical care. I
will argue, however, that payments or other material
benefits for impoverished research subjects are
sometimes not only morally acceptable but required.
Protection of vulnerable populations is generally
based on a conception of “respect for persons.”
Although Kant is not always invoked by name in ethicaldiscussionsofresearch
involvingvulnerable
populations, the language used is generally Kantian. At
the least, arguments for how to protect such
populations are deontological in nature. The Belmont
Report states that the principle of “respect for persons”
makes two distinct moral demands: “the requirement toacknowledge autonomy and the requirement to protect
51
those with diminished autonomy.” Poverty diminishes
autonomy, and extreme poverty or disease can reduce
51

Belmont Report in The Ethics of Research Involvingst
Human Subjects: Facing the 21 Century, ed. by Harold Y.
Vanderpool (Frederick, MD: University Publishing Group,1996), 439.

people to the status of objects, albeit objects
demanding our care and attention. The Belmont Report
also expresses concern for vulnerable populations interms of justice. Injustice occurs, according to thereport, when someone is denied a deserved benefit or52
unfairly forced to endure an unequal burden. As an
example of unjust distribution of burdens and benefits,
the report mentions that nineteenth-century research
was often conducted on poor ward patients with privatepatients receiving most of the benefit. Principles ofjustice demand a fair distribution of benefits andburdens. Any groups that risk harm should be likely toreceive benefit as a result.
Violations of respect for persons or autonomy
expressed in deontological terms do not permit
justifications based on outcomes. It is not acceptable toviolate the autonomy of one research subject even if
the research will benefit millions of people. In thissense, deontological protections seem to be in directcontradiction of teleological concerns for research that
focuses primarily on outcomes.
Generally, research is justified when the possible
benefits of the research outweigh the risks of harm that
may result from the research. In an ideal world, theresearch will yield benefits in the form of cures fordevastating diseases and greatly alleviate suffering.
Much research has been aimed at curing or eliminating
diseases such as polio, small pox, AIDS, and cancer.
Researchers have enjoyed enough success thatpeople with life-threatening or extremely painful
conditions (another vulnerable group) will often
demand to be included in research protocols, thinking
experimental treatments are the best treatments
available. In some cases, they are the best available,
but the purpose of research is to confirm this, so
individuals seeking experimental therapies may
inadvertently be demanding to receive a dangerous
substance.
Research protocols are justified on utilitarian
grounds. When a researcher proposes research on an
experimental therapy, the proposal must identify thepossible goods that will result from the therapy.
Research that has no anticipated benefit or that poses
great risks should not be considered worthwhile. At theleast, experimental protocols should enhance scientificknowledge with an aim to developing beneficial
treatments in the future. The fact that treatments are
sold for profit complicates the calculation of risk andbenefit. In order to increase profits, a pharmaceuticalmanufacturer may make only slight changes to an
existing drug to make it easier to swallow or moreconvenient to store in hopes of increasing profits
through new patents and licensing agreements. A
manufacturer may see a protocol for such a drug asproviding great benefits in the form of increased profit
with little risks to research subjects as the researchsubjects are taking a drug almost identical to an
existing drug. The primary benefit is not the alleviationof suffering and disease or even medical knowledge
but an improved marketing of a known substance.
52

Ibid., 441.

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Such research protocols are frequently approved.
Another complication is that manufacturers sometimes
develop therapies for niche markets.
While profit is seen as a legitimate benefit for
manufacturers, it is not seen as a legitimate benefit for
research subjects. In fact, the use of financial
incentives for research subjects is problematic for mostethicists. The concern is that financial inducements
may be coercive and cause impoverished individuals totake risks they would not take if they were more
affluent. In the worst case, researchers would be
exploiting the desperation of the poor to benefit theaffluent. In fact, in many cases drugs are tested on thepoor with little chance of ever benefiting the poor. For
example, Havrix was tested as a vaccine for hepatitis A
53
in Thailand on poor school children. The primary goalof the researchers was not to find a way to eliminate oreven reduce hepatitis A among school children in
Thailand. Rather, although the researchers made averbal commitment to pursue registration of Havrix inThailand, the researchers’ primary intent was to market
the vaccine to travelers as protection from hepatitis A
54
when visiting Thailand. Nonetheless, Thai citizens
benefited from the research in some ways. Somechildren did receive the Havrix vaccine, and all children
in the study were vaccinated against hepatitis B. Also,
clinics and storage facilities were improved in order tostore the vaccine, and the research team visited
schools with hepatitis outbreaks to identify
improvements that could help prevent the spread of thevirus. Those who objected to the study complained that
there was no plan to provide Havrix to Thailand at afree or reduced rate, Thai researchers were notadequately involved in the study, and Thai caregivers
were not given adequate training to reduce theincidence of hepatitis.
Some would argue that the Havrix trial promotes theprinciple of utility. Citizens of Thailand received somebenefit from the trial, and others will continue to benefit
from the development of a vaccine for hepatitis A. The
use of children in Thailand might be justified by thebenefit to a greater number of people in the future.
Objections to the study seem to be rooted in principlesof “respect for persons” and justice while justifications
for the study are utilitarian. It appears that anyone
evaluating the ethics of the research must operate in
two moral worlds: one for justifying research andanother for protecting subjects. I argue that a Utilitarianframework can consistently be used to justify research
but also provide consistent arguments for theprotection of subjects. The advantage of adopting a
Utilitarian perspective is that it does not require
ethicists to jump from one foot to the other whenevaluating protocols.
The arguments for the Havrix trial are, indeed,utilitarian, but they do not meet the requirements of aphilosophically grounded Utilitarian standard. Utilitarian
53

Jennifer S. Hawkins and Ezekiel J. Emanuel, Exploitation
and Developing Countries (Princeton: Princeton University
Press, 2008), 55.
54
Ibid., 56.

moral theories are often expressed as advocacy for thegreatest good for the greatest number. Indeed,
Utilitarians do claim that morality should attempt topromote the greatest good possible, and it may
occasionally involve sacrificing a few in order topromote good for many. As an example, many civilrights workers in the United States in the past havesacrificed their leisure, their liberty, and their lives toensure a future where racial equality might become areality. Many of these workers knew they would not live
to see greater equality, but they felt the sacrifice wasjustified. As formulated by Jeremy Bentham, theutilitarian calculation of benefit for the greatest gooddemands an impartial examination of the good foreveryone involved with equal consideration given to all.
The conflict between these two calculations is often
described as a conflict between Act Utilitarianism andRule Utilitarianism. Act Utilitarianism is said to be thebelief that individual actions are deemed morally
acceptable if they provide more pleasure or happinessthan unhappiness. Critics can easily provide crude andhorrifying counter examples. Gang rape might bejustified because several people derive pleasure fromthe violation of only one person. Faced with such
examples, Utilitarians are expected to slink away inshame for having offered such a preposterous theory.
In response, some have claimed that Rule
Utilitarianism is a more consistent and intuitively
acceptable theory. Rule utilitarianism holds that actions
are laudable when they conform to behavioral rulesthat tend to promote happiness for everyone. Ruleutilitarians recognize that individual actions cannot be
isolated from overall social consequences. Gang rape
is now prohibited, as any rule that permitted rape would
create a hostile climate for anyone who might become
a victim of a sexual assault, and such potential victims
make up the majority of the population. Utilitarianism isrestored, but it seems to have taken on a deontologicalcharacter. Some would argue that this is a way of
being a Kantian while wearing a Utilitarian mask.
Such confusion with Kantianism is not necessary,and divisions between Act and Rule Utilitarianism aresuperfluous. The basic utilitarian principle is that wemust seek to promote the greatest overall satisfaction
for everyone affected. An Act Utilitarian who failed toconsider future consequences or social consequences
would be failing as a Utilitarian on the surface. The
assertion of Rule Utilitarianism is only necessary when
Utilitarianism is misapplied. At the most, Rule
Utilitarians remind Act Utilitarians of the demand forequal consideration. Whether Utilitarianism in this form
is Kantian specifically or deontological generally is amore difficult question. Deontologists claim to promotea morality that is right and good regardless of desirable
or undesirable outcomes. A famous example comesfrom Elizabeth Anscombe, who said it is neveracceptable to boil a baby, even to save a thousand
lives. This is a stark admonition to ignore the outcomeof an action and follow inviolable moral rules. It is hard
to imagine any deontologist, however, saying that
following such rules would make life less enjoyable forthe majority of people. In fact, the purpose of morality

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in whatever form is to promote peace and happinessfor most people. If murderers, thieves, and liars areless happy for our moral codes, then so be it.
With regard to research that may be exploitative,
utilitarianism demands consideration for the interests of
all involved, including the most vulnerable. Being
reduced to extreme poverty is a bad thing in itself.
Further, promoting the dignity and well being of thosein poverty is a good thing. Researchers have an
opportunity to either exploit the dignity of theimpoverished or take actions to enhance dignity andalso relieve their poverty. The concept of dignity is noteasily defined, but I will simply say that we act topromote dignity when we recognize the interests ofothers and attempt to help promote their interests.
Mutual engagement and inclusivity promote feelings ofdignity. Actions that reduce people to mere means
violate principles of respect for persons but also violate
principles aimed at promoting general welfare.
The divergence between Kantian respect for persons
and utilitarian concern for the interests of all is smaller
than some expect. The principle of utility is derived
from what promotes happiness. Hume asserted that
our moral beliefs or intuitions are based on sentiment.
When we make moral judgments about the wrongnessof murder or lying, we are making a judgment about
what pleases or displeases us. When we recognize
what makes us disgusted or uncomfortable, we
express the sentiment as a moral rule. We then use
reason to further develop formal moral rules that reflect
our sentiments or passions. Kant demands that reason
operate independently of emotion. For Kant, we should
examine the rightness of our actions by whether they
can be willed to be universal. This sounds quite
different, but given that Utilitarians assume thathumans share a common aversion to pain andsuffering, Utilitarian considerations will also beuniversal. Utilitarians demand concern for others
because each individual wants concern for herself.
Kant also says that the person who denies love andcompassion to others will be choosing to deny love andcompassion for himself. Utilitarianism and Kantian
ethics each conclude that we must be concerned for
our fellow sufferers in life. With respect to research
ethics, I prefer a utilitarian framework, as it isconsistent with the language of justification forresearch.
If we accept the general utilitarian principle thateveryone should be concerned for the well being of
everyone else, it stands that the goal of medical
research should be to relieve as much pain andsuffering as possible. Bringing a sense of dignity tothose who have been robbed of their dignity is a noble
goal. Medical research can do this in a number ofways: 1. Research might cure diseases that plague
individuals, restoring them to autonomous andindependent lives. 2. Research might involve
individuals in a process that can help improveconditions for others, thereby giving a sense of
purpose and meaning to their lives. 3. Researchers
may help to alleviate extreme poverty.

Impoverished individuals may have few opportunities
to feel they are making a meaningful contribution tosociety. The opportunity to enhance medical orscientific knowledge can give them a sense of meaningand productivity. In order for their participation in
research to preserve or augment their feelings of selfworth, though, several conditions must be met.
Individuals must be fully informed of the goals of theresearch and participate in a fully engaged manner.
This is not to imply that they must share the expertiseof the researchers but only that they must be seen as
partners or joint venturers in a project that can benefit
society as a whole. The researchers must recognizethat the subjects have their own individual goals that
motivate them to participate. Beyond recognizing thosegoals, researchers must work with the researchsubjects to help them understand the progress of theresearch.
In addition, as in all protocols with all populations,researchers must fully inform potential researchsubjects of the risks of participating and any possible
benefits they might accrue. Deception or withholding of
critical information is never acceptable. Finally,
researchers should attempt to leave all subjects in noworse shape than they were in before they began the
research. In addition to making every effort to leave
individuals in no worse shape than they were in at the
beginning of the research, investigators must also
make every effort to leave communities at least as welloff as they were at the beginning of the research.
Obviously, adverse events are not predictable inexperiments, but researchers must do their best to
minimize adverse events.
In 1994, researchers discovered that zidovudine(AZT) could prevent transmission of HIV from motherto baby. Pregnant women would begin taking AZT in
the second trimester and take it for a minimum of 12
weeks at a cost of about USD10,000. Most HIVinfected pregnant women lived in developing countries,
and approximate spending on health care in thosecountries was about USD10 per person annually. In
Uganda, annual spending was less than USD3 perperson. In the hope of reducing costs, researchers
proposed doing research in developing countries suchas Tanzania, Ethiopia, Kenya, Uganda, and Zimbabwe
to test whether a short-term AZT-treatment might beeffective in preventing maternal-fetal HIV transmission.
All but one of the trials used placebo controls and 9 of
16 were funded by the National Institutes of Health and55
the Centers for Disease Control.
In a 1997 letter to the U.S. Secretary of Health andHuman Services and following commentary in the New
England Journal of Medicine, Peter Lurie and Sidney
Wolfe condemned the trials as unethical because theuse of placebos was not justified given that anothertreatment was known to be more effective (longer-term
AZT). Defenders of the trials argued that the researchsubjects would not receive any treatment in theabsence of the trial anyway, and were therefore noworse off. Critics noted that the trials would be
55

Ibid., 1 – 2.

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Eubios Journal of Asian and International Bioethics 23 (November 2013)

unethical if conducted in the United States asregulations would prohibit the use of placebo wheneffective treatments were available. Defenders claimed
that the poor economic conditions of the countries
where the trials were taking place made the researchmore necessary. If shorter-term treatments wereshown to be effective, treating women in developing
countries could prove to be more affordable.
Nonetheless, sponsors of the AZT trial made no
guarantees to offer the treatment at an affordable cost
56
posttrial.
The International Ethical Guidelines for Biomedical
Research Involving Human Subjects, published by theCouncil for International Organizations of Medical
Science (CIOMS), states that any research carried out
in underdeveloped countries be “responsive to thehealth needs and the priorities of the community in
57
which it is to be carried out.”
Furthermore, incommentary to guideline 15, the document says, “As ageneral rule, the sponsoring agency should agree inadvance of the research that any product developed
through such research will be made reasonably
available to the inhabitants of the host community at58
the completion of the successful testing.” It may beargued that the therapy was complete upon the birth of
the baby, so that continued treatment was notnecessary for any individual participating in the trial.
The question then is whether the research is
responsive to the health needs of the host community.
If the goal of the research is to find affordable
alternative treatments for developing countries, thenthere can be little defense of the research if the hostcountries cannot afford even short-term therapy, which
would cost approximately USD50 per person.
If this trial was begun in order to find affordable
therapies for underdeveloped countries, it seems
unreasonable to begin the trial knowing that thecommunities involved could not continue even therelatively inexpensive treatment. If the trials wereactually developed in hope of finding improved
treatments for women in developed countries, the trials
certainly constituted exploitation. This seems unlikely,
however, as most HIV-positive pregnant women lived
in developing countries.
It is possible to argue that participants in the
research did benefit from the research in that somebabies were protected from HIV infection. Babies in thecontrol group who became infected were not harmed
by participation, as they would have become infected in
the absence of the trials. Some argue that communities
should benefit from participation in research, but that it
is not necessary for access to treatment posttrial be
one of the benefits. According to Hawkins andEmanuel, such critics argue, “What is a requirement isthat the host community actually benefit fairly from theconduct and/or results of research. But providing

medication post-trial is not the only way the community
59
might benefit.”
I would argue that if the sponsors of the researchcannot reasonably provide treatment posttrial (in somecases, the treatments are not proven effective after one
trial and in other cases the sponsors have noreasonable method for distributing the treatments),
then it may be reasonable to offer other benefits in
exchange for participation. Regarding payment forparticipation in research, the CIOMS guidelines say,
Subjects may be paid for inconvenience and timespent, and should be reimbursed for expenses
incurred, in connection with their participation in
research; they may also receive free medical services.
However, the payments should not be so large or the
medical services so extensive as to induce prospective
subjects to consent to participate against their better60
judgment.
This requirement is intended to prevent unscrupulous
researchers from using incentives as a form of
coercion to compel subjects to expose themselves torisks that more empowered individuals would notconsider. Alternatively, the guidelines could say that noresearch should be conducted that entails risk so greatthat no affluent person would give consent. In otherwords, the research should not be conducted on thepoor simply because it is too risky for the wealthy. If
this condition is met and researchers have sought tominimize risks for all participants, then restricting theamount of payment that is permissible only constrains
the liberty of participants. Further, compensation that is
too low may make participation available only to
comfortably well off subjects. While excessive payment
may be coercive, insufficient payment can be
exclusionary.
One does not need to be desperately poor to be
subject to inducements. Many people who live fairly
comfortably are willing to take risks to their lives inexchange for higher pay. For example, some aredrawn to completing construction contracts in war
zones partly for the high pay and partly for theexcitement they derive from participation. When people
agree to work in a war zone, they generally understandthat they are involved in extremely risky activity, but
individuals in drug trials often do not seem to fully
understand the risks. In 2006, the U.S. drug company,
Parexel paid eight men about USD3,500 to participate
in phase I research of TGN1412. Within hours, all six
men receiving the active drug suffered organ failure.
The men were not poor. One victim was raising money61
to pay for his wedding. Another of the victims was acollege student who just wanted to earn some extra
cash. A family friend said he did not think there would
62
be any problems. These men did not choose to59

Ibid, 10.
Vanderpool, 504.
61
Rob Sharp, “’Elephant Man’ cancer victim breaks hissilence,” The Observer, August 6, 2006. Guardian.co.uk
accessed 12/19/08.
62
Dani Veracity, “TGN 1412 drug trial update: One patient
may lose fingers and toes due to drug side effects,”
60

56

Ibid., 2 – 9.
Vanderpool, 506.
58
Hawkins and Emanuel, 9.
57

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participate because they could not afford to refuse.
They chose to participate because they did not fully
understand the risks, probably because the sponsorsof the trial also did not understand the risks and did not
expect any serious adverse events. If the risks had
been accurately stated and everyone involved
understood that using experimental drugs always has arisk of serious side effects, then the agreement toparticipate would be justified, and a higher payment fora higher risk would be reasonable.
In underdeveloped countries, ethicists raise more redflags, though. There is concern that participants willlack the understanding of the trial necessary to makean informed decision. It is conceivable that in somecases, the prospective participants have no way ofunderstanding what research is or what the risks ofparticipating may be. When such prospective
participants are identified, they should not be permitted
to participate in the research; however, sponsors
should not assume that poverty in itself negates ones
ability to understand and negotiate contracts. Justicedemands that participants understand that they are
involved in research that entails risks, that the research
may not or will not (when this is known) benefit them
therapeutically, and that they be engaged withresearchers throughout the trial in a manner that
continually emphasizes the nature of the research
project.
In the case of the AZT trials, Utilitarianconsiderations would demand a number of conditions
for the research to take place. First, the goal of theresearchers must be to reduce disease, suffering, anddeath. It appears that this may well have been thecase, but the long-term effects of the trial were notadequately considered. If the treatment was designed
primarily for women in countries that could not afford
the treatment at any cost and the sponsor could notprovide the treatment for the countries involved, theresearch had no justification for taking place. If this is
not true, and the research was intended to benefit
women in affluent countries who could afford thetreatment, then it is an unjust distribution of burden andbenefits.
Second, research sponsors should ensure that
communities and individuals participating in the
research will benefit from their participation. Benefits
could come in a variety of forms. Fully informed
subjects might agree to participate simply for theopportunity to contribute to the greater good of society.
So long as they agree with full understanding that they
are sacrificing their time and risking harm in hope of
benefiting others, it is laudable to provide an
opportunity to include them in a productive andmeaningful activity.
Third, when researchers are not providing
therapeutic benefit to the community, it is possible forthe community to benefit from improved comfort care,
improved training for healthcare providers in thecommunity, and improved health care facilities or
NaturalNews.Com,
12/19/08.

www.naturalnews.com

accessedtechnology that will stay in the community. In suchcases, the participants may not benefit from thetreatments being researched, but they will still benefit
from improved care. Sponsors should make every
effort to maximize benefits.
Fourth, researchers should make every effort toleave both communities and individuals as well off asthey were before the research began. Some adverse
effects cannot be predicted as was apparently the casein the Parexel trial, but the long-term effects on the
countries participating in the AZT trials seem
predictable. Ironically, negative effects on thecommunity were the result of the success of thetreatment. Demonstrating the effectiveness of atreatment that will not be available to the community
can only have a demoralizing effect. Beginning aclinical trial knowing that this is the best outcome
possible violates the principle of equipoise at thecommunity level. Although some babies were sparedHIV infection, the overall effect on the community was
negative.
Finally, when researchers discover a possible
therapeutic benefit, they should make every effort tomake the treatment available to as many individuals
and communities as possible. How therapeutic benefit
will be maximized should be explicitly stated andnegotiated before any clinical trial begins. The AZT
trials had a stated goal of finding more affordable
treatments, but no long-term plan for financing
treatment was negotiated or, apparently, evendiscussed.
A September 2008 article in the Journal of the
National Medical Association examines the ethicalissues of conducting genetic studies with African
immigrants as the subjects. The article notes that theseimmigrants are classified as a vulnerable population by
the Department of Health and Human Services Agency
for Healthcare Research and Quality because they
face culture shock, language barriers, prejudice, anunfamiliar legal system, and economic hardship. One
issue raised in the article is profit sharing. The authors
note that discoveries from genetic research could yield
millions of dollars. Failing to share the profits with theindividuals providing the genetic information necessary
for developing the treatments amounts to “biopiracy” or“biocolonialism” according to some critics of suchresearch. The authors conclude, “It is possible that a
promise to share financial gain with research
participants may provide more incentive for potential
subjects to participate in research and change the63prospect of future research.” Rather than asking
whether it is ethical to use payment as an inducement,
researchers should ask whether it is ethical to withhold
payment when enormous profits may result from thewillingness of research subjects to participate. Shared
63

Gordon Gong, Sade Kosoko-Lasaki, Gleb Haynatzki,
Cynthia Cook, Richard O’Brien, and Lynne E. Houtz, “Ethical,
Legal, and Social Issues of Genetic Studies with African
Immigrants as Research Subjects,” Journal of the National
Medical Association, Vol. 100, No. 9 (September 2008): 1075
– 1076.

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Eubios Journal of Asian and International Bioethics 23 (November 2013)ownership in the research project is one way ofenhancing a sense of dignity and empowerment inparticipants, but one might ask whether it is ethical for
pharmaceutical companies to generate (or retain) suchenormous profits in the first place. The relief of poverty
is of utmost concern to most Utilitarians. If companies
will generate enormous profit, it makes sense that
economically disadvantaged research subjects shouldshare in some of the profit, but a robust Utilitarianism
would demand that the profits be used to alleviate
poverty to the greatest extent possible. This would
certainly be an unpopular position, but ethicists should
not take positions based on how popular they will bewith corporations. Instead, concern for the welfare of
our global community should motivate both our ethicalpositions and our behavior.
The purpose of this paper is not to refute
deontological theories of ethics or justice as I believeboth deontological (especially Kantian) and teleological(especially Utiltarian) theories demand concern forsocial justice and compassion for vulnerable
populations who are possible victims of exploitation. I
do claim that Utilitarianism can provide a consistentframework for both the justification of research and theprotection of human subjects. It is not necessary totoggle between theories when discussing research
protocols. Further, I assert that when research
protocols are designed well, payment for participation
is a matter of fairness, not exploitation, and payment
may help promote human dignity.

On the patenting of life:
Ethical, medical, andeconomic repercussions- Nitarshan Rajkumar
A former high school student from Chennai, India; Currently a
student at Waterloo University, Canada
Email: rajpooja@gmail.com

The genes in your body are shared with virtually
every other human being in the world, and are a part ofthe common heritage of humankind. Your genes are a
product of nature, as are the clouds in the sky, thewater in the sea, and the air you breathe. None ofthose things can be patented, so why is it that over
one-fifth of your genes already are (Jensen & Murray2005)?
By letting biotechnology firms own the genes in ourbodies, we are allowing them reduce those genes tomere commodities, letting them be bought and sold as
if they were nothing but a pair of gloves or boots.
Treating such a fundamental piece of the heritage of
our species as private property is regarded as an insult
to our fundamental human dignities and freedoms, andan affront to decades of genetic research. The whole
notion of patenting genes, however, seems totallyparadoxical. The very definition of a patent suggeststhat it is for the protection of an invention. In contrast,
genes are quite the opposite of an invention; they are a
product of nature. Yet biotechnology companies havestill obtained patents on them by stating that theirsizable investment during the research anddevelopment of the gene should be rewarded withcomplete intellectual property rights to it (Crichton2006).
What’s worse is the fact that many of thesecompanies are allowed to patent an entire gene justbecause they’ve extensively researched a very specificapplication of it. It’s as if I can patent computers
because I’ve spent the last 25 years researching theiruse in playing video games. Sure, computers are used
for many other purposes, but since I was the firstresearcher to ask for a patent, I got it. Because I havea complete monopoly over the use of computers now, itmeans that companies that produce and sell
keyboards, mice, computer components, andcomputers themselves are going to have to pay me a(rather handsome) royalty because their products
directly rely on computers for their applications. Not
only that, but you will need to pay me a fee to use yourcomputer; otherwise I can fine you and send you to jailfor violating my patent. Though all this may seemutterly ridiculous, it is exactly what is happening in thestrange world of gene patents.
However, it is important to keep in mind that there
are more than just ethical and philosophical dilemmas
to the patenting of genes; the real world effects ofthese patents are catastrophic for patients and theirfamilies. Gene patents delay the development of lifesaving treatments, greatly drive up the costs of drugs
and tests, and hamper the progress of medical
research. This is not at all what should be happening
with patents.
A patent should first and foremost be used to foster
innovation within the scientific community, not hinder it.
When one research group patents a method A for
diagnosing breast cancer, another research groupwould quickly begin working to find a method B. This
competition creates additional methods of diagnosing
the cancer (a valuable second opinion), and helps
significantly reduce treatment costs for the patient(Borger 1999). With gene patents however, that is not
the case. As a gene is not something that can beinvented, granting a patent on one would shut the door
closed to other researchers. This severely limits thestudy of that gene, and raises costs for treatments
associated with it as the owner of the patent cancharge whatever he likes due to the lack of competition(Crichton 2007).
A very alarming example of how gene patents hinderresearch was during the outbreak of the SARS in 2003.
During the outbreak of the virus, researchers were
hesitant to study the disease because of confusion
surrounding three separate patent claims to it (Rimmer
2004), and the fear of facing charges of patent
infringement. The virus ended up killing over 700
people; some of whom might have been saved if
researchers had had quick and unrestricted access tothe virus, without fears of expensive patent-

219

Eubios Journal of Asian and International Bioethics 23 (November 2013)

infringement litigation. This “tragedy of the
anticommons”, in which competing interests prevent
progress and development, greatly slows down
biomedical research, which in turn means patients will
have to wait longer for new methods of medical
treatments (Heller & Eisenberg 1998). This is mostevident today with statistics showing that over half of
all laboratories have stopped development of
diagnostic tests because of concerns over infringing
patents, and one in four laboratories are forced toabandon a clinical test in progress because of
conflicting gene patents (Holman 2008).
However, gene patents are not only hurting
independent laboratories, they are also hurting
patients. A key example would be for a test for mutatedversions of the breast cancer related genes BRCA1and BRCA2. This test could easily be done byindependent laboratories for under $1000, yet today it
has an asking price of over $3000 because Myriad
Genetics (the owner of the gene patent) does not letanyone else offer the test, giving Myriad a monopoly
over pricing for tests for those genes (Andrews 2002).
Even worse, the tissue samples used for the testing
become the property of Myriad, and anything of interest
found in that sample can be used commercially andeven patented in itself, all without your permission or
knowledge (Bovenberg 2005). If you don’t like that,then you can’t take the test, and as there are no otherplaces to go for testing, you are left unaware as towhether or not you are developing cancer.
Gene patents pose an enormous threat to medical
research. Because of these patents, costs for needed
tests and treatments have skyrocketed, andcompetition has been removed. This lack ofcompetition directly affects many researchers working
to find new methods of saving lives, causing the speed
and intensity of their research to greatly decelerate.
When their research and progress suffer, our future
suffers. It is time to put patients before patents.
Bibliography
Jensen K. and Murray F. (2005) Science 310, 239-240
Jensen, Kyle, and Fiona Murray. “Intellectual Property
Landscape of the Human Genome.” Science 310 (2005):
239–240. Print.
Heller M. and Eisenberg R. (1998) Science 280, 698-701
Heller, Michael A., and Rebecca S. Eisenberg. “Can Patents
Deter Innovation? The Anticommons in Biomedical
Research,” Science 280 (1998): 698-701. Print.
http://www.austlii.edu.au/au/journals/MelbJIL/2004/14.html
Rimmer, Matthew. “The race to patent the SARS virus: the
TRIPS agreement and access to essential medicines.”
Melbourne Journal of International Law 5 (2004):335–374.
Print. http://www.escholarship.org/uc/item/7rr0w5gf
Holman, Christopher M. "The Impact of Human Gene Patents
on Innovation and Access: A Survey of Human Gene
Patent Litigation." UC Berkeley: Berkeley Center for Law
and Technology. eScholarship, 2008. Web. 26 Jan. 2010.
<http://www.escholarship.org/uc/item/7rr0w5gf>.
http://journals2005.pasteur.ac.ir/NB/23(8)/929%20%20933.pdf
Bovenberg, J. “Whose tissue is it anyway?” Nature
Biotechnology 23(2005):
929–933.
Print.
http://www.handsoffourovaries.com/pdfs/appendixe.pdf

Andrews, Lori B. “Genes and patent policy: rethinking
intellectual property rights.” Nature Reviews Genetics 3(2002): 803–808. Print.
http://www.nytimes.com/2006/03/19/opinion/19crichton.html
Crichton, Michael. “This Essay Breaks the Law” The New
York Times 19 Mar. 2006: WK13. Print.
Crichton, Michael. "Bodysnatchers, 2006." Wall Street
Journal [New York] 15 Dec. 2006: A20. Print.
http://www.nytimes.com/2007/02/13/opinion/13crichton.html
Crichton, Michael. "Patenting Life." The New York Times 13
Feb.
2007:
A23.
Print.
http://www.guardian.co.uk/science/1999/dec/15/medicalresearch.genetics
Borger, Julian. "Rush to patent genes stalls cures fordisease." The Guardian. The Guardian, 15 Dec. 1999.
Web.
26
Jan.
2010.
<http://www.guardian.co.uk/
science/1999/dec/15/medicalresearch.genetics>.

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AUSN Conference on Bioethics, Public Healthand Peace for Indigenous Peoples, 29 June
2014, Mexico City, Mexico [the day after the
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