Eubios Journal of Asian andInternational Bioethics
EJAIB Vol 20 (6) November 2010www.eubios.info

ISSN 1173-2571

Official Journal of the Asian Bioethics Association (ABA)
Copyright ©2011 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page

Editorial: New ABA Board
169
Changing Perspective on Obesity: Genetic andEnvironmental Health Consequencesin the Offspring170- Tiffany Delport and Irina Pollard
Presence in Suffering: Lessons from the
Buddhist Four Noble Truths
173- Michael C. Brannigan
Some Ethical Thoughts from the Indian Tradition 180- Ravichandran Moorthy & Sivapalan Selvadurai
The Winter of Clinic? Advanced Ethical Dilemmas
for an Advanced Medicine
183- Paolo Cattorini
Sex Selection in Asia, with a focus on Thailand 190- Napat Chaipraditkul
Thai perspectives on abortion
198- Anniken Celina Grinvoll
Asian Bioethics Association Election Results
200
Editorial address:
Prof. Darryl Macer, RUSHSAP, UNESCO Bangkok,
920 Sukhumvit Rd, Prakanong, Bangkok 10110,
THAILAND
Fax: Int+66-2-664-3772 Email: d.macer@unesco.org

Editorial: New ABA Board
On the top of the page you will find the logo of
Eubios Ethics Institute, representing the three
countries from which we operate. Of course itreaches out across the world in a large network. Thisthis the last issue of the 20 year, next year starts thest
21 year. Asian bioethics is certainly coming of age
in its reflection, and the first issue of 2011 will be adouble issue containing a detailed analysis ofJapanese bioethics. On the last page of this issue
are the results of the 2010 Asian Bioethics
Association (ABA) elections, which see almost an
entirely new board of members, which start inprinciple the fourth new board of the ABA. I also

congratulate the new president of ABA, Anoja
Fernando, the first woman president of ABA, whotakes over from Leonardo de Castro. Thanks tothose who have renewed their membership of ABA,
and to all the previous board members – who we
hope continue like those before to develop bioethicalreflection and research in Asia and the Pacific.*
This issue of EJAIB includes six papers exploring
themes relevant to the theory of bioethics, as well as
the practice of Asian bioethics. Delport and Pollard
review obesity which is an epidemic in the region,
with a number of causative factors. It can be
expected to contribute to even more health problems
in the future than today. Education to empower
citizens to make good choices can overcome this,though we still
Brannigan explores Buddhist understandings of“presence”, through suffering. He considers how U.S.
health care may not treat pain well. The same could
be said for many systems, including those in
Buddhist countries. There are also papers in thisissue by Grinvoll, and Chaipraditkul, which present
results of interviews and review of abortion, and sex
selection, in Thailand with references to Buddhist
thinking. A number of stereotypes found in theirresearch may apply across the world also, andwomen‟s health is a very important and stillneglected issue in many countries.
Moorthy and Selvadurai look at ethical worldviews
from an Indian tradition, largely from Hinduism butwith multicultural undertones which are acrossreligions found in Indian culture. Cattorini examines
ethics and advanced medicine. On the web two
supplementary issues for November 2010 are booksof abstracts from UNESCO-UKM conferences being
held 29 November – 3 December in KL, Malaysia.
For those readers interested in Ethics andIndustrial Meat Production, the major source ofgreenhouse gas emissions, please visit the new
website of www.unescobkk.org/rushsap to download
a new book publication from ECCAP working group
13.
-Darryl Macer* order form from www.eubios.info/ABA.htm

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

Changing Perspective on
Obesity: Genetic andEnvironmental HealthConsequences in the
Offspring- Tiffany Delport and Irina Pollard
Department of Biological Sciences,
Macquarie University, Sydney,
New South Wales 2109, Australia
Email: irina.pollard@mq.edu.au

Abstract
The prevalence of obesity and overweight hasreached epidemic proportions with globally morethan 1 billion adults being overweight and an
estimated 400 million clinically obese with a1projected rise to over 700 million by 2015 . The
condition – once affecting only high-income countries– is now a major global health concern touching allcommunities across all ages and socioeconomic
groups. The traditional view that overweight andobesity is exclusively the result of over-indulgence inenergy-dense, nutrient-poor foods with high levels ofsugar and saturated fats is widespread. This is notnecessarily the case promoting an urgent need toraise awareness about the multidisciplinary origins of
this condition. For example; maternal exposure to avariety of
fat-dense
diets
under
differing
environmental conditions and fetal developmental
phases may adversely impact upon metabolic
parameters predisposing the infant to an increased
risk of overweight and obesity in early childhood, andreduced fertility later in adult life. By emphasizing thatthe condition maybe the product of both past andpresent
circumstance,
wearechallenging
contemporary food security improvements. It is forthis reason that the present review focuses on boththe science and the ethics. Bioscience ethics canusefully be linked to the discipline of epigenetics –namely environmentally triggered changes in gene
expression promoting lasting legacies in subsequent
generations. Importantly, epigenetic insights reveal
how positive or negative environmental influences
may promote resilience, or otherwise, in theoffspring. By integrating ethics and the life sciences,unique educational opportunities for advancing
biological understanding within the scaffolding of
ethics can be created.
Keywords: Obesity, fetal metabolic programming,
epigenetics/epigenome, bioscience ethics, addiction,
stress.
Introductory BackgroundObesity, the prevalence of which has seen an
almost exponential rise, is an “energy imbalance”
disorder resulting in excess fat accumulation in thebody, mostly within the subcutaneous tissues. The
1World Health Organization. Fact Sheet no. 311. Geneva:
WHO; 2006

accumulation of fat, stored mostly as triglycerides inadipose tissue, is caused by a greater caloric
ingestion than is required for producing energy
needed in daily activities. The most widely usedmeasure to indicate the presence of this condition isbody mass index (BMI), which, by comparative
analysis of an individual‟s weight to height ratio,
determines a range of adaptive body fat
2
percentages. A BMI of 25-30kg/m is defined as astate of overweight, whereas a state of clinicalobesity is represented by a BMI of greater than2
30kg/m [1]. When body mass indices are referred toin this review, obesity is defined as a body mass2
index of ≥30kg/m . It is important that attention be
drawn to the fact that this body index does not take
into account individual body characteristics such as
differing body type morphologies, athletic versus
shapely, nor does it allow for measurements ofweight to specify bone and muscle density. By
considering only total individual mass and excluding
metabolic efficiency, obesity simply highlights acondition of over-consumption. While it is undeniable
that obesity is a result of energy intake andexpenditure imbalance, underlying aetiologies may
suggest, for example, alteration in glucose and lipid
metabolism [2] or vascular dysfunction [3].
An appetite for foods dense in fats and sugars is
the result of selection of adaptive physiologicalcharacteristics that evolved in our distant huntergatherer ancestors. During that phase of ourevolution the ability to store energy reserves in theform of adipose tissue was adaptive in seasonalenvironments where periods of limited foodavailability – starvation even – was predictable [4,5].
Since then our physiology has remained little
unchanged; thus, in contemporary society where
foods are abundant, individuals are ill adapted to this
newfound bounty currently triggering a global
epidemic of morbidity and ill health [6,7,8].
Obesity in Pregnancy and Early Infancy: LongTerm Metabolic Consequences
There exist periods of vulnerability during fetal
development where the types of foods the mothereats may increase the risk of overweight and obesityin the offspring. For example, during the third
trimester of pregnancy, epigenetic drivers in the formof increased portions of processed, energy-densematernal food intake, will up-regulate the transport oflipids as free fatty acids across the placenta which, inturn, will accelerate the generation of fat cells within
fetal adipose tissue [9,10]. Development of additional
fat cells, in unison with increased fetal/placental
circulating levels of leptin, is likely to predispose theoffspring to a larger than average gestational weightand increased appetite during childhood; thus,
perpetuating the trans-generational effects ofoverweight and obesity [11]. Leptin, the hormonal
product of the OB (obesity) gene, is produced inadipose tissue and plays a significant role in thecentral regulation of energy expenditure (including
appetite and metabolism) as monitored by the„appetite centre‟ of the brain‟s hypothalamus [4,12].
Under normal adult conditions, leptin acts as an
endocrine signal on the hypothalamic receptors

Eubios Journal of Asian and International Bioethics 20 (November 2010)
where it inhibits appetite; however, consistently
elevated leptin levels, as in obesity, may impair thisfunction. On the other hand, leptin – also widespreadin fetal and placental tissues – acts as a potent fetal
growth factor [9]. Before birth, leptin production
promotes growth by increasing the mobilization ofmaternal fat stores in order to further support fetal
growth. It should be noted that towards term, anumber of structural and functional maturationalchanges occur in the fetus in preparation for thetransition from intrauterine to extrauterine life.
Particularly relevant to the present discussion is thatduring the last trimester‟s growth phase, fat
represents over 50% of fetal caloric accretion.
Maternal „flavour preference‟ can also be passed
on to the offspring during the period of breastfeeding,as well as during third trimester gestation. Clinical
trials monitoring possible periods of flavour
development preferences identified a critical period
spanning 3-4 months postnatally [13]. Infants were
exposed to two baby formulae with differing flavour
characteristics; cow‟s milk-based and hydrolysed
protein-based milk. Despite a sour, bitter taste andunpleasant odour, infants that were previously
exposed to the hydrolysed protein-based formulaover the four month course of the trial, became more
accepting of the unpalatable formula [13]. Similarly,
exposure to specific nutrient-dense foods during
breastfeeding can result in infant preference to thisspecific food type. For example, earlier clinical trials
found that the type of formula fed during infancy
influenced taste preference at ages 4-5 years [14].
These and similar findings demonstrate that early
exposure to specific „flavours‟ does impact uponlearned food preference where behaviouralassociation with energy-dense foods establishedduring critical developmental periods, may affectcertain neurological adaptations that increases a
distinctive pleasant reinforcement response, when
the food is consumed later in life. As a consequence,
the beginnings of overweight and obesity are partly
contributed to by intrauterine conditions during
development, as well as infancy and dietary choices
made in later life. For this reason, it is crucial that
informed parental behaviours associated with foodintake are established prior to gamete formation andconception, as well as during pregnancy andbreastfeeding. Parents, who are better informed
about reproductive physiology [15], become more
responsible behaviourally, reducing the risk of theiroffspring developing obesity or overweight [16].
Awareness of how individual choice andcircumstance can influence both individual andgenerational health, through the advancement of
biological knowledge of both the genetic andepigenetic contributors to a high body mass index,
will improve societal and individual understanding ofobesity.
Obesity and Fertility Outcome
Individuals who are more vulnerable to a genetic
predisposition of higher body weight often experience
reduced reproductive fitness. A greater weight,

171

especially distributed around the abdominal region, isassociated with reduced fertility in both women andmen. Fertility irregularities can be identified early via
changes to the balance of circulating hormones; suchas leptin, which can result in adverse effects
controlling normal regulation of neuroendocrine
function driving maturational changes towards theattainment of puberty [17]. As described above, leptin(part of the adipokine regulating system) is a productof adipose tissue so circulates in the body at a higher
concentration in obese or overweight persons,compared to those of lesser mass. The adipokine
system is central in the adjustment and timing of theonset of gonadotropin-releasing hormone (GnRH)
secretion that drives the hypothalamic-pituitarygonadal axis to initiate the processes that culminate
in puberty [18]. Owing to high circulating levels of
leptin in overweight young girls, the onset of puberty
is premature compared to their lesser weightassociates. With the occurrence of the first menses
at an earlier age, it is also predicted that this group of
women will experience menopause at an earlier age[19,20]. In any event, it has been well establishedthat a state of obesity influences fertility inreproductively active women by adversely affecting
the development of gametes (eggs) that may thencontribute to the trans-generational effect of obesityand possible reduced fertility in turn [21]. Decreased
reproductive capability, or fitness of offspring, isfurther enhanced when the gamete is fertilized by amale partner who is also overweight or obese.
Male infertility has been little discussed until
recently with the primary focus for its cause attributed
to an imbalance of hormone concentrations. As agreater weight reduces metabolism essential for
sperm serum production, men who are overweight orobese often have decreased plasma levels of sex
hormone-binding globulin (SHBG), which lowers thelevel of circulating steroid hormones [22, 23]. Men
2with a body mass index exceeding 30kg/m , with alarge proportion of adipose tissue distributed aroundthe abdominal region, are further likely to experiencelower levels of total testosterone and freetestosterone due to the enzyme aromatase in fat
tissue, which aromatizes testosterone to estrogen[24]. The combination of reduced semen quality andlow testosterone, progressively result in lower sperm
count, increased sperm with abnormal morphology
and decreased fertilizability [25]. Overweight orobese individuals are approximately three times
more likely to develop these fertility anomalies than2
men with a body mass index of less than 30kg/m[26]. As a result, clinically obese men are more likely
to have greater fertility difficulties that may adversely
affect the next generation of infants: hence, further
contributing to the trans-generational effects ofobesity.
As many individuals are unaware of the
progressive generational predisposition to inherit
reduced fertility status, it is crucial that information
regarding the influence of obesity and overweight on
future generations be made available. By distributing
knowledge of the applied science through bioethics

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

education, individuals can be made more aware of
their choices and provide better long-term health inoffspring by reducing their vulnerability to develop thebasis of adult disease in utero.
Sedentary Lifestyle and Increased Food
Availability
Since the beginnings of human evolution, we haveadapted physiological mechanisms to cope with dailyrequirements of physical exertion and the storage ofenergy reserves for periods of starvation.
stProgressively leading into the 21 century, lifestyles
have adapted to become more sedentary with alessened physical role in both the workforce andtraditional home functions. As technologicaladvances have allowed us to become more efficientin daily processes, the energy requirement for dailyfunction is much lower now than a century ago.
Hypothetical models of energy requirement haveestimated total daily expenditure a century ago to bearound 3000 kcal/day whilst under modern living
conditions, daily energy requirement for physicalactivity is estimated around 500-1000 kcal/day; 3060% lower than past decades [27]. In addition, total
body fat composition is negatively correlated withbasal metabolic rate (BMR) because fat consumes
lower energy per unit weight compared with muscle[28]. For this reason, individuals with an inherited
predisposition to store excess fat may, involuntarily,
be more likely to gain weight as a result of asedentary lifestyle. Further, as a result ofphysiological adaptation to a higher daily caloric
intake and levels of circulating dopamine – the feel
good neuro-hormone – individuals can develop an
addiction to our primordial taste preference,increasing the risk of developing overweight or
clinical obesity. However, despite the nature of theworkforce changing, there still remain numerous
opportunities to exercise and consume foods lower insaturated fats and sugars, suggesting that
progression from overweight to obesity is, to a great
extent, determined by individual lifestyle choices. As
many of the outcomes of compulsive consumption of
fast-foods, such as reduction in basal metabolic rate
and potential addiction, are largely unknown by manymembers of contemporary society, it is crucial that
this knowledge be made easily accessible in order toheighten individual and community awareness.
Summing up: The Ethics of Science
From the biological perspective, health and illhealth are not alternative states; rather they are partof the same continuum where genetic and epigenetic
influences sustain, or derail, normal reproductive
processes triggering lasting legacies in the next andsubsequent generations. As described in this review,
we inherit more than just our genes from ourancestors. Inadequate control over the decisionmaking in one‟s life generates a destructive interplayof social, physical, economic and environmental(epigenetic) factors that undermine the determinants
shaping the wellbeing continuum. Like all of us,
fetuses have mechanisms by which they adapt todeteriorating environmental conditions brought about
by parental distress, drug abuse, disease, nutritional

excess or deprivation, and non-adaptive lifestyles. In
essence, normal development is disrupted byharmful influences and for those surviving theirprenatal challenges, the cost maybe a struggle withlong-term health consequences [29]. By facilitating
information transfer based on biology relevant tocontemporarysociety,
futurestudies
will,
progressively over time, provide a basis for individual
knowledge and the opportunity for the establishmentof informed decisions associated with food intake. As
obesity is the second most common cause ofmorbidity and mortality in modern times, it is crucial
that further work also focuses upon the fetal origins
of obesity and its trans-generational occurrence.
Figure 1 allows the reader to see the rapidity ofweight increase as measured in some selectedOECD countries. The hoped for outcome is that withready access to ongoing scientific investigations,existing societal mores will change and facilitate
informed
individual
choicesupportingthedevelopment of a positive foundation to maximize
trans-generational health.

Figure 1: Published in The Weekend AustralianFinancial Review 9-10 October, 2010, p. 27.(Source
http://economix.blogs.nytimes.com/2010/09/23/the-world-is-fat/ )References
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2. Vasquez G, Duval S, Jacobs Jr D, Silventoinen K.
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3. Romero-Corral A, Montori V, Somers V et al. Associationof bodyweight with total mortality and with cardiovascular
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4. Cripps R, Martin-Gronert M, Ozanne S. Fetal andperinatal programming of appetite. Clinical Science
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5. Philipson T, Posner R. The long-run growth in obesity as
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9. Forhead A, Fowden A. The hungry fetus? Role of leptin
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Gambineri A. Obesity and reproductive disorders inwomen. Human Reproduction Update 2003;9:359-372.
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Meikle A. Male obesity and alteration in sperm
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173

Presence in Suffering:
Lessons from the Buddhist
Four Noble Truths- Michael C. Brannigan, Ph.D., M.A.
Pfaff Endowed Chair in Ethics and Moral Values
Department of Philosophy & Religious Studies
The College of Saint Rose
432 Western Avenue, Albany, NY 12203, USA
Email: michael.brannigan@strose.edu
Faculty, Alden March Bioethics Institute, Albany Medical
Center, Albany, NY 12208

Abstract
The core of Buddhist teaching compels us toaddress and relieve the suffering of sentient
creatures in the best ways we can. However, U.S.
healthcare has not sufficiently faced this challenge.
Despite undeniable progress in efforts to medicallycontrol pain, U.S. healthcare delivery stills struggles
in coming to terms with fundamental aspects of pain
and suffering, for instance in chronic and terminal
illness. I argue that one major factor lies in an
increasing forgetfulness of what I consider the “virtueof presence” and its associated distinction between
curing (treating) and healing. Within this context, I
will more closely examine Buddhist views of
suffering, healing, and presence, focusing particularly
upon the Buddhist Four Noble Truths. Although the
Truths date back over two millennia, certain
teachings resonate in our ongoing clinical encounter
with pain and suffering. Buddhist insights help toreaffirm necessary ingredients in genuine presence.
Moreover, they lend weight to the proposition that
U.S. healthcare has much to learn from othertraditions and perspectives.
I conclude byreasserting our need, more so today than ever, tocultivate presence.
Introduction – Western Medicine’s Pyrrhic
Victory
In The Worst of Evils, a brilliant tour de force
recounting the cultural struggle against pain,
chemical pathologist Thomas Dormandy describes
the ordeal of the impressionist painter Pierre-Auguste
Renoir (1841-1919) whose bicycle injury, rheumatoid
arthritis, and later paralysis of arms and legs left him
wheelchair-bound during his last nine years [1]. At
that time in the early 1900s, Western medicine met
with little success in treating the type of unrelenting,chronic pain that Renoir endured. After the reputed
Viennese Professor Rudolf Schade treated thepainter for two weeks with a steady diet of herbal
medicines, he assured him he could now walk.
Renoir‟s son Jean, the celebrated film director,
recounts the episode in his biography, Renoir, My
Father. He describes how his father, to others‟
astonishment, arose tentatively from his wheelchair,and found strength to walk slowly across the room[2]. Upon returning to his chair, utterly exhausted,
the painter realized that walking would entirely
consume any energy left for painting. But at least he174

Eubios Journal of Asian and International Bioethics 20 (November 2010)

now had the choice. He chose to remain in his chair,and despite his deformed hands and crippled fingers,
he painted masterpieces like A bunch of roses (inmemory of his wife who died in 1915) and Portrait ofMadam de Galea. With the help of Richard Guino,
he even sculpted pieces such as Venus Victrix.
Although his physical pain persisted, his suffering
was in a sense relieved. Whereas prior to Schade‟surging, the painter felt inescapably imprisoned in thewheelchair, he now had some semblance of control.
When it comes to pain and suffering, we areengaged in a domain of meanings.
Whereasphysicians imprint an objectivity through assigning
medical meaning to a patient‟s condition, the patient
lives out that condition in a subjectivity that isengulfed within an intimately personal, familial,social, religious, and cultural web. Renoir‟s domainof meaning centered around his passion for his art.
The patient‟s subjective domain of meaning
underscores the phenomenological distinction
between pain and suffering. However my pain islabeled, it remains my pain. How I perceive andunderstand my pain becomes my suffering.
Moreover, my meanings affect the course of myillness, which in essence remains a personal
interpretation of a condition just as suffering is apersonal rendition of personal pain. For instance,
meanings that I bestow upon my chronic headaches
no doubt change if my physician discloses a tumor in
my brain. And my meanings are further altered upon
disclosure that my tumor is inoperable. My sufferingrests upon the meanings I give to such „facts‟ andultimately remains my suffering.
None of this is novel. Over six decades earlier
French philosopher Maurice Merleau-Ponty offered
his penetrating incision into the existential nature ofillness, reminding us that, though a disease may beascertained as an objective entity, a person‟s lived
experience of that pathology is entirely subjective
and constitutes the real meaning of illness [3].
Theologian Paul Ramsey reached further though lessdeeply, lamenting the disappearance of the “person”
who, once institutionalized and objectified, becomesstamped a “patient” [4]. The metamorphosis is
deceptive, for the patient is always first and foremosta person.
Not long after Renoir, Western medicine achieveda remarkable string of victories in ways to medicallycontrol pain. Landmarks include discovering both therole of neurotransmitters in conveying signals, andeffective agents in treating pain such as
norepinephrine, dopamine, serotonin, Nembutal,
amphetamines, metamphetamines, and aspirin. In
due course the triumph of penicillin and generalanesthesia empowered Western medicine to gain theupper hand in controlling acute pain [1]. Yet, medical
conquest of acute pain undermined efforts to address
chronic conditions such as rheumatoid arthritis,
Parkinson‟s Disease, deafferentiation (the phantom
limb in Merleau-Ponty‟s Phénoménologie de laPerception), and “non-specific” ailments like lower
back pain as well as those associated with terminal
illness. Equally significant, medical control over pain
meant less attention to the personal suffering
induced by the pain. During Renoir‟s time, prior to

successful pain-control, it was the obverse.
Physicians, more or less helpless in assuaging
physical pain, could at least offer solace and comfort
in addressing their patients‟ suffering [1].
Western medicine‟s Pyrrhic victory – improved
pain control accompanied by diminished interest in
suffering – reflects medical attentiveness to what isvisible and known. Whereas a disease category is
grasped, measured, and objectified, a patient‟s lived
experience of his or her illness remains invisible tomedical inspection, less measurable during the
medical interview, and entirely subjective. What isless visible becomes less “real.” For instance, apatient‟s personal narration has less fact-value thanthe disease category of hypertension, which, as avisible and known category, can at least be
addressed through typical drug regimen. My lived
experience of my hypertension however is of lessaccount. What matters is known etiology.
Despite its continuing conquest of pain,
healthcare‟s perennial challenge lies in its struggle tocome to terms with pain and suffering.
This
constitutes the litmus test of medicine. Furthermore,this compels medicine to acknowledge its limits intreating persons, for persons suffer, whereas bodies
do not.
Aim
All this is a roundabout way of introducing mypurpose in this essay, which is to travel back in timeand revisit leading ideas from millennia-old Buddhist
Four Noble Truths to assess their applicability totwenty-first century Western medicine. My reason isstraightforward. The Four Noble Truths form theheart of Buddhism in that they directly address
suffering as a universal truth and propose ways toalleviate not just one‟s own and other humansuffering, but that of all sentient beings. Along theway, we have much to learn from the Buddhist
prescription. One prominent lesson centers around a
notion which I believe represents a chasm in ourcurrent healthcare delivery – a commitment to theexercise of active presence. Through Buddhist
insights, I underscore the importance of presence sothat we may cultivate it within healthcare in ways that
become through force of habit second-nature.
Buddhists scholars may disapprove of mysimplified exegesis.
Nonetheless, in the spirit of
Buddhism, the text, like diagnostic technique, is atool, not an end-in-itself. As the Buddha instructs themonk Malunkyaputta, one who is shot with apoisoned arrow is not concerned with the make-up of
the arrow, but with being free from the arrow [5]. Asa tool to help us free ourselves and others from
suffering, the Buddhist Four Noble Truths, as applied
to our current U.S. medical climate, contributes to an
ethics of presence.
Back to the Living Past – The Four Noble Truths
What makes the Four Noble Truths “noble”?
These truths lay bare the nature, origin, and relief ofsuffering. Given the centrality and misery induced bysuffering, the question is all the more fitting.
According to the Majjhima Nikaya, the “Middle

Eubios Journal of Asian and International Bioethics 20 (November 2010)
Length Discourses” of the Buddha, their nobility liesin their undeniable facticity.
These Four Noble Truths, monks, are actual,unerring, not otherwise. Therefore, they are called
noble truths [6].
In addition, philologist K. R. Norman, who admits
that the translation “noble” lends itself tomisinterpretation, asserts that these truths areespoused by the noble one, the Buddha.
Furthermore, through acknowledging and embracingsuch truths, we in turn become noble [7].
For our purposes, Norman‟s analysis is instructive.
The Truths correspond to a medical diagnosis in thatthey point to a particular condition (suffering, or
dukkha), specify the cause of that condition (trsna),
indicate that we can be relieved from the condition(nirodha), and prescribe the way to relief (marga). It
is not surprising that the Buddha is also referred toas the Great Physician, the Healer. He embodies
what healing is all about. Physicians, by virtue of
their commitment to relieve pain and suffering, areennobled. In turn, medicine is a noble profession.
Let us further explore these ennobling truths byusing as our centerpiece the parable of Kisagotami,
described by the fifth century Buddhist commentator
Buddhaghosa in his Vissudhi Magga (Path of
Purification).
Kisagotami became in the family way, and when
the ten months were completed, gave birth to a son.
When the boy was able to walk by himself, he died.
The young girl, in her love for it, carried the deadchild clasped to her bosom, and went about fromhouse to house asking if anyone would give hersome medicine for it. When the neighbours saw this,they said, “Is the young girl mad that she carries
about on her breast the dead body of her son!” But awise man thinking to himself, “Alas! this Kisagotami
does not understand the law of death, I must comfort
her,” said to her, “My good girl, I cannot myself give
medicine for it, but I know of a doctor who can attend
to it.” The young girl said, “If so, tell me who it is.”The wise man continued, “Gautama can give
medicine, you must go to him.”
Kisagotami went to Gautama, and doing homage
to him, said, “Lord and master, do you know of any
medicine that will be good for my body?” Gautama
replied, “I know of some.”
She asked, “Whatmedicine do you require” [8]?
Gautama, the Buddha (literally “awakened one”),
then instructed her to go to each neighbor and collecta mustard seed from every household that has not
faced death. She did as instructed, hearing different
responses from villagers, some having lost a child,some lost parents, and some lost slaves. In sharing
with Kisagotami their own personal stories, they
offered a common response, “The living are few, but
the dead are many.”
At last, not being able to find a single house where
no one had died, from which to procure the mustard
seed, she began to think, “This is a heavy task that I
am engaged in. I am not the only one whose son isdead [8].”175With this realization, she then left the body of her
dead in the forest and returned to Gautama. Thoughempty-handed, she was now filled with insight having
learned the law of death.
Gaumata said to her, “You thought that you alone
had lost a son; the law of death is that among all
living creatures, there is no permanence [8].”Noble Truth One - Dukkha
Kisagotami acquired insight into the law of death
and, in doing so, realized the First Noble Truth - thatpain and suffering, dukkha, permeates existence.
Although the Pali term dukkha is typically translated
as “suffering,” it literally means “dislocation,” anunease, a „dis-ease‟ that more profoundly embodies
Kisagotami‟s predicament.
Her visits with each household – the text leaves it
to us to imagine the details – must have gradually
impressed upon her the full scope of dukkha, notonly its utter pervasiveness, but that it is life‟simpermanent nature itself which generates suffering.
The painful memory of her son‟s death rouses her
sense of dislocation, his dis-ease. Furthermore,since nothing is permanent, then neither is his or her
entity called “I”. For Buddhists, this “I” or “self” simply
supplies an anchor of security in this ocean oftransience, and we have no real grounds to confirm
that “I” exists without begging the question. Thislatter aspect of suffering (sankhara-dukkhata),
evoked by the “I” illusion, is exceedingly difficult for
those of us conditioned to believe in a separate,
independent, and permanent self.
Buddhistschallenge our ontic bias by reducing who we are to
five components, or skandhas: form (body),
sensation, perception, mental constructs, andconsciousness. These represent our physical andmental states, and together, they comprise ourindividual being and identity; there is no separate self
as overseer, no “ghost in the machine.”
In all this, it is crucial to appreciate that
Kisagotami‟s insight into the law of death comes
about through her person-to-person encounter andengagement with others who shared her suffering.
Through her neighbors, in a sense her medical team,she gradually recognizes that in her suffering she is
not alone. Hers is thus a parable of recognition, andpresence plays a major role. She also recognizes
that through shared suffering, “she” is notindependent and separate from “them.”Sheeventually awakens to her oneness with herneighbors, indelibly linked through suffering. Hereinlies the key. Recognition can only come about
through presence, indeed a reciprocal presence ofeach person to the other, an inter-presence. This
inter-presence is strong medicine and leads toKisagotami‟s awakening, which in turn leads to herhealing. Through the medicine of recognition andpresence, and in turn inter-presence, “I” can now
more easily enter into the suffering of the “other” andvice versa.
This is also a parable of healing, for healingmeans to restore what is broken, to repair what is
torn apart, to make whole. The ultimate aim in176

Eubios Journal of Asian and International Bioethics 20 (November 2010)

medicine is to heal. And healing clearly requirespresence.
Gautama‟s medicine consists inprescribing to Kisagotami a face-to-face encounter
with her neighbors. He instructs her to present
herself to them, and in doing so, they present
themselves to her and with her. And with eachencounter, each inter-presence, she ultimately
realizes the fundamental truth that she is not, neverwas, nor ever will be alone.
Noble Truth Two - Trsna
In the course of our diagnosis, the second Noble
Truth underscores the root cause of our suffering,
trsna, usually translated as “desire.” I prefer thetranslation “craving,” the extreme form of desire.
Craving occurs when our desires, most notably thedesire for permanence, overcome us, as was clearly
the case with Kisagotami who desired medicine forher dead son. Unable to let go of her son‟s death,clinging to a past in which her son was alive,
Kisagotami was attached to the idea of permanence.
She was further attached to the illusion of a separate
identity, the idea that she alone was suffering, that“she” was different and apart from any “other.”
Again, through her inter-presence with her„medical team,‟ she in time recognized the sharednature of her plight, that she was not alone in her
suffering. In the classic Mahayana text Vimalakirti
Sutra, the enlightened disciple Vimalakirti instructs usthat our personal suffering enables us to enter into
the suffering of others.
The suffering of herneighbours enabled them to enter into her personalplight. By virtue of their presence to her and withher, she entered into their suffering as well,recognized her oneness with them, and thus
awakened to the illusion of separation between her
and all others.
Noble Truth Three - Nirodha
The Third Noble Truth represents the turning pointin the Buddhist diagnosis and sets the Buddhist
approach apart from the current state of much ofWestern medical science. It tells us that, as in thecase of Kisagotami, we can indeed be relieved from
suffering. Suffering is not cast into the category of“untreatable condition.”
As healers, we must
recognize suffering, address it, and work to alleviateit.
The Buddhist prognosis is thoroughly optimistic.
Because suffering permeates one‟s being, medicine
not only strives to relief it, but it can. Kisagotami‟s
encounter with her neighbors treats and relieves her
suffering. Their mutual presence, inter-presence,each being open to and present with the other,enables her healing.
Although the medicalprescription for healing in most cases requires morethan simply presence, presence is a necessary
condition.
Noble Truth Four – the Eightfold Path
Because suffering is treatable, the fourth noble
truth provides a detailed treatment regimen. Thisprescription, the Eightfold Path, consists of steps allof which interact with each other. It is important tonote that these eight paths are not separate. As withmultiple drug treatments, they all interact. The
seventh path in particular - right mindfulness –directly focuses upon the need for presence. At thesame time, presence assumes significance in eachof the others.
Path One
Right understanding, embracing
Buddhist teachings as a necessary means to relieve
suffering, requires that one must be present to theseteachings, open to them in a way that allows theirinsights to penetrate.
Path TwoRight intention demands that we
cultivate the proper attitude, to be free from selfcenteredness and from the delusion of duality
between “me” and the “other.”
Kisagotami‟swillingness to listen to her neighbors and to be open
to whatever they had to share with her, allowed forinter-presence, their mutual openness to each other.
Path Three Right speech means what it says.
In the Samyutta-nikaya, the Buddha warns hismonks:“In sooth to every man that’s born
A hatchet grows within his mouth,
Wherewith the fool, whene’er he speaks
And speak amiss, doth cut himself…”[9]Right speech thus illustrates the force of karma,that principle of moral causality in which every action
with moral weight inevitably produces consequencesthat are either productive or destructive, so that ourcharacter affects and is affected by our speech.
This is especially germane in terms of how I
interact with a patient. Right speech involves a
twofold presence. It requires self-presence in that I
am present to myself, aware of my inner state in thecompany of others. It also requires that I be present
to and for the other whom I am with. Right speechdemands that I actively listen and reflect before
speaking, a hard lesson in our excessively noisy andchatty culture, absorbed much of the time in what
German philosopher Martin Heidegger referred to as“idle talk” [10].
Path Four
Right
actionmeans
selflessbehavior. It therefore proscribes lying, stealing,
behaving unchastely, wrongful killing, etc.
And
selfless action certainly requires being present to, for,and with others, for it demands placing the needs ofother living beings first.
Path Five
Right livelihood requires that weengage in occupations that nurture selflessness. In
so doing, right livelihood demands a similar presence
to, for, and with others, especially with our coworkers throughout our eight, ten, twelve, fourteen or
more work-hours per day.
Path Six
Right effort beckons us to develop
the discipline to always act in selfless ways. As withright speech, discipline is not a popular term in our
public lexicon, but it is vital in Buddhist practice. For
example, Buddhist meditation requires our mental
discipline to be totally present to ourselves in both
body and mind. Self-presence is a prerequisite todiscipline and demonstrates right effort.
Path Seven Right mindfulness speaks directly
to the meaning of presence, insisting that we be fully
attentive, aware of where we are, how we are, when
we are, and with whom we are. As I see it, rightmindfulness sums up the essence of Buddhist

Eubios Journal of Asian and International Bioethics 20 (November 2010)teaching, that is, to be where we are when we are
there. This is absolutely imperative in the clinicalsetting where the patient, already physically andemotionally compromised, is situated within an
institutional context that appears highly impersonal.
Being-there, as simple as this seems, is profoundly
difficult.
Path Eight Right meditation represents theideal state in which, via presence and all of the priorsteps, I transcend the conventional duality between“I” and “other” and awaken to the truth that there isno separate “I” nor “non-I.” As long as Kisagotami
assumes that “she” is separate from her neighbors,
her suffering is all the more agonizing. Her gradualrealization that her suffering is shared dissolves theprotective wall she had built between herself and theworld. Inter-presence and the realization of nonduality leads to healing.
Back to the PresentWith this snapshot view of Buddhist teachings, let
us now apply the above notions of presence tocontemporary healthcare. In the process, what more
can we assert about presence? The clue lies in theword‟s existential, spatial, and temporal bearings.
Presence means “being present,” and to “be present”
one must “be there in the present,” not somewhere
else other than where one is, not stuck in some past
nor playing out some scene in the future. This iswhat right mindfulness is all about. To be present
with one who is suffering is exceptionally challenging
since suffering entails anguish over loss of what was
past as well as fear towards some future. Being
present requires securing ourselves in the present,
wherever that present takes us.
Medical Interview
One of the most important and, from the patient‟s
point of view, most impressionable encounters
between physician and patient is the initial medical
interview. The medical interview consists in figuring
out what is wrong with the patient. It requires
knowing the complaint, understanding the complaint
within the broader contexts of the patient‟s medical
and personal history, and getting a good pulse on thepatient‟s perspectives, concerns, and expectations[11]. Here, presence is undeniably crucial.
Figuring out what is wrong with the patient takes
time, not necessarily lots of time, but time that is wellspent. Time is the scarcest medical resource forhealth professionals under the gun of fiscal andprofessional pressures.
I continue to hear an
ongoing litany from providers and nurses that they
simply do not have lots of time to spend with each of
their patients. In many cases, they have goodreasons, given institutional constraints, recurring
systemic dysfunction, and a lack of care-continuity.
In some cases, however, such reasoning can be an
expedient excuse for insufficient and improper
attention to patients. In all cases, as I have regularly
stressed in numerous meetings with medical staff, it
is not the amount of time that matters, but how thattime is used, or wasted. Presence is the key. And

177

unless we can learn to better cultivate presence, we
ourselves will continue to hinder healing and, for thatmatter, treatment.
In Margaret Edson‟s 1999 Pulitzer Prize winningplay Wit, Chief of Medical Oncology Harvey Kelekian
and others transform Vivian Bearing, Professor ofEnglish with a specialty in the metaphysical poetry ofJohn Donne, by objectifying her into the disease shebears, late stage metastatic ovarian cancer. As
clinical Fellow Jason Posner conducts his medical
interview with her, he awkwardly demonstrates anear total absence of presence. The fact that he is aformer student of the patient adds further insult [12].
A cold detachment occurs in the clinical encounter
when the health professional is more attentive to the
medical data, the “facts,” than to the person before
him. This takes on a special cruelty when that
person is dying. Contrast this with the inter-presence
that must have eventually developed between
Kisagotami and her neighbors. So, what in particulardoes this presence require?
Ingredients in the Virtue of Presence
Active listening
The medical interview prompts us that presenceneeds to be established from the start.
Activelistening provides the key. Active listening engages
the whole person. We convey our messages in three
ways: the words we use, our tone of voice, andnonverbally, for instance through body language.
Communication studies reveal that we are much
more attentive, and thus attribute more importance,
to both nonverbal cues and tone of voice than to thewords themselves.
Clinical oncology consultant
Elisabeth Macdonald rates this attentiveness at 60%
for nonverbal cues, 35% for tone of voice, and 5% tothe spoken words [11]. Bodily presence is no doubt
indispensable. With our socio-cultural infatuation
with mobile phones and text messaging, think of how
we might feel if physicians text-messaged to us ourdiagnoses. Active listening therefore requires that
we listen to both what is not said and what is said,
along with how all of this is conveyed. As we
described above, the Buddhist path of right speech is
not only about what is spoken, but how it is said, andespecially what is left unsaid.
Silence is its own voice, so that presence mustallow silence to have a „say‟ in the encounter. This isdifficult in a culture that thrives on noise and talk.
Yet, according to the Swiss philosopher Max Picard,silence is the ground of speech, without whichspeech is uncomprehensible [13]. Silence is thereby
its own profound language. Indeed the language ofsilence is the most difficult to learn. Active listening
requires listening to this language, especially in theclinical setting where patients are exceptionallyvulnerable and their suffering is intensely intimate.
While we may control the agenda by filling in thecavities of silence with speech, our effort oppresses
the truths which only silence can convey.
The small truth has words that are clear; the great
truth has great silence. (Rabindranoth Tagore, Stray
Birds, CLXXVI)

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

Pace
An inherent power-imbalance in the clinicalencounter between physician and patient requiresthat we empower the patient by allowing the patient
to set the pace. Although the physician necessarily
pursues an agenda, provides direction, and guides
the patient along the way, the physician can also
control the agenda through interruptions and closed
questions that may discourage the patient fromrevealing more of the important context behind theinitial complaint. The Buddhist path of right action
underscores acting selflessly, in that we put aside
our own agenda, our own narrative, in order to begenuinely present to, for, and with the other and fully
listen to his story, and not our own. The physician
can further control the agenda by focusing solely
upon the presenting complaint so that the complaint
becomes the problem, apart from the broader context
of the patient‟s personal, familial, and social history
and habits.
Medical tests to ascertain diagnoses are no doubt
invaluable. As Public Health expert Eric Cassell
points out, assurances provided through medical
techniques, diagnostic procedures, and tests mayhelp soothe the discomfort of uncertainty given thefact that each patient responds to his or her condition
and treatments in unique ways [14]. Yet a moral
turning point occurs when reliance on technique andprocedure supersedes interpersonal engagementwith the patient. For instance, a pivotal scene in theclassic Japanese film Ikiru (To Live), directed by
Akira Kurasawa, depicts two physicians seemingly
fixated on the x-ray image of the patient Kenji
Watanabe‟s malignant stomach tumor [15].
Watanabe‟s suffering is profoundly and indelibly real.
Yet images threaten to replace the patient in thehierarchy of importance, perniciously becoming more
real than the reality they depict. When faith intechnique trumps faith in what we can learn from our
encounter with the patient, medical intervention
undercuts the healing power of presence.
Reciprocity
The primordial premise in the Buddhist Noble
Truths highlights the intimate and synergistic
interconnectedness among all living beings. This is
the teaching of pratityasamutpada, co-dependent
origination. All actions, particularly interpersonal, arethereby cause and effect. We see this in the path ofright livelihood, which encourages us to engage inoccupations that cultivate selfless action, and which
can be further nurtured through selfless encounter
with others.
This presents a special challenge in the noble
profession of medicine. An authentic relationshipbetween the professional caregiver and the patient
can only unfold in a climate of trust. Without trust, a
relationship of potential healing risks becoming one
of suspicion, doubt, and adversity, a climate ripe for
medical litigation. Since by its nature presence tends
to be reciprocated, presence helps to establish andensure trust. That is, the medical team‟s proactive
presence often evokes presence on the part of thepatient and family. This reciprocity is the interpresence I alluded to above in the story of

Kisagotami.
The physician‟s genuine and felt
presence sends the most important message to thepatient – that he or she is valued. The patient
naturally responds more openly.
To summarize, through active listening, pace, andreciprocity, presence embodies the fundamental
condition of “being present.” This sets in motion“being-present-to.” The healer is a professional who,in the desire to heal, presents his or her competence
and expertise to the patient. Presence is also “beingpresent-for,” in that the healer‟s commitment to thepatient‟s well-being operates on a more humane,covenantal level that goes beyond a relationship thatis minimalist, impersonal, and merely contractual[16]. Moreover, presence is “being-present-with.”
The healer does not work alone, but works together
with the patient and the medical team in partnershipwith the patient, and at the same time seeks tosustain a bond of trust with the patient and family.
Finally,presence
includes“being-present-intranscendence.” The quality of the healer/patient
relationship transcends its immanence in a way thatreflects the deeper mystery of their unique encounter
in which matters of faith and deep-rooted spirituality
occupy a privileged place, embodying in the deepest
sense the nobility of the medical profession,
Conclusion - Presence as release from thetyranny of time and mind
It is enormously difficult to cultivate these
ingredients of presence - active listening, pace, andreciprocity - within our U.S. healthcare system,
principally because our health system reflects deeprooted cultural values. The healthcare provider‟squandary represents a socio-cultural predicament.
We are increasingly consumed by an incessant needto accomplish as much as we can in less time. With
information technologies that enable us to “stayconnected” and “plugged in,” we find ourselves
ensnared in a range of diverse contexts that require
never-ending responses through speedy andconvenient digital communications and multi-tasking,in turn elevating these to a level of virtue. The ability
to stay focused on single tasks, one-at-a-time, is not
only becoming a rare species but even regarded as ahindrance to moving forward and keeping pace withthe traffic. We have come to believe that we have notime for one-at-a-time thinking, reflection, andresponse. Likewise, medicine moves forward in
multiple contexts, appearing increasingly disjointed
and without a coordinating center, a symphonyorchestra without a conductor. As a result, ourhealth system is dangerously fragmented in waysthat threaten both continuity and quality of patientcare.
On account of two culprits, Time and Mind,
providers encounter extreme difficulty embodying
presence with their patients. Under the pressure oftime, within a context of medical uncertainty in viewof each patient‟s uniqueness, the patient‟s problem
stands in danger of being defined strictly within
diagnostic categories that objectify the patient‟s
subjective experience of illness. Lack of sufficient
time requires that we efficiently get to the complaint,
figure out the problem, and resolve it, the operativeEubios Journal of Asian and International Bioethics 20 (November 2010)
term noting “it” as the problem. Within this densely
multi-directional system, providers understandably
find themselves under the axe of time andinstitutional pressure to perform in cost-effective
ways that not only sustain the system, but protect
their job security within the system. Yet this comesat a cost, and the patient, who in principle should
always occupy the moral center of their professional
concern, pays the price, for the patient‟s problem orcomplaint has been transformed and translated as
the problem.
Presence, being where-we-are-and-with-whomwe-are, is also profoundly difficult, not only forphysicians but for all of us, because, as the Buddhist
text Dhammapada reminds us, the mind is like anelephant. Tamed, it quietly makes its way throughthe forest. Untamed and unrestrained, it rampages
through our mental terrain taking us in different
directions at once, so that we become easily
distracted from where we happen to be. In our
encounter with patients, distraction exacts a high toll
for the stakes are high. Instead of listening to what issaid, how it is said, and what is left unsaid, we let ourown agendas speak to us and allow our minds to pullus away from being-present to, for, and with ourpatient. This means rewinding to the complaint
which translates into the problem, reviewing different
treatment regimens, considering additional tests toconfirm (and to protect ourselves down the line).
The Buddhist philosopher Nagarajuna, in hisbrilliant Mulamadhyamikakarika, cautioned us
against becoming fixed to ideas, concepts, and othermental baggage. Fixation to what is not real (ourthoughts) pulls us away from our lived presence in
our interaction with the other, who is real. Fixation
provides us with a safe detour away from the realityof the suffering patient before us. Yet how we arepresent to the one who suffers will shape the extent
and degree of that sufferer‟s healing.
One of the many invaluable lessons that I havelearned from my work with patients, particularly
hospice patients, is that patients themselves detect
whether or not we-are-there-with-them. Our bodylanguage gives it away: eye contact, where our eyes
go, what we do with our hands, the way we fidget,looking at our watch, whether and where we stand orsit, whether we write more or listen. How wemaneuver our physical environment also gives itaway. Is there sufficient privacy and quiet? Have weturned off our pagers? Are there physical barriers
such as tables, desks, chairs, notes, clipboards, etc.
between physician and patient? For the patient,these physical barriers represent significant
meaning-filled walls. These add up to that lessvisible quality known as sincerity. I suspect that ourown personal experiences as patients would confirm
this.
Those in vulnerable circumstances areespecially sensitive to, alert, and intuitive regarding
the visitor, whether neighbor, hospice nurse,
volunteer, or physician.
It seems as if ourvulnerability somehow unveils our intuitiveness to thevulnerabilities of others and their discomfort with or
expression of sincerity and presence.

179

In conclusion, what I consider to be the virtue ofpresence requires that we cultivate the skill and theart of using the little time we have, which may be all
the time we really need, in the best way we can. It
goes without saying that we bring our experience,expertise, and competence to the encounter. Yet
presence demands much more. How we manifest
our presence forms the vital condition for healing.
On our part, this requires patience, attentiveness,
mindfulness, active listening, reassurance, and care.
It entails being-there-with-our-patient. How we arewith the patient, the person before us, not only
makes a difference; it is the difference.
Acknowledgements
Through the kind invitation of Rev. Chris Degiovine todeliver the Sidney Albert Annual Lecture at the College ofSaint Rose, I was fortunate to share some of these ideas. I
remain grateful to Father Chris, the Board, and all others
who offered valuable feedback. I also thank Professors
Srikant Sarangi (University of Cardiff), Peter Schulz(University of Lugano), and Per Måseide (Bodø University
College) and all those who attended the University ofCardiff‟s Health Communication and Research Center
Summer School for their insightful comments on mypresentation regarding the need for Presence inhealthcare. My special thanks as well go to Dr. Joan
Collison, Professor of Psychiatry, Kansas University Schoolof Medicine, for her invaluable observations on the subjectof presence.

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Some Ethical Thoughtsfrom the Indian Tradition- Ravichandran Moorthy, Ph.D.
Senior Lecturer in the Programme for Strategic andInternational Studies, Faculty of Social Sciences andHumanities, University Kebangsaan Malaysia
Email: drravi5774@gmail.com- Sivapalan Selvadurai, Ph.D.
Senior Lecturer in the Programme for Development
Science, University Kebangsaan Malaysia
Kuala Lumpur, Malaysia
Email: sivap02@gmail.com

Abstract
In the pre-World War II era, Western powers
colonized many countries in different regions of theworld. In the greater Asia region, Western powers
like the Portuguese, British, Dutch and the American
divided the region into their own sphere of influence.
Through centuries of occupation, the occupiers
managed to introduce certain way of life, conducts,
norms and values into the local population. Slowly,
Western precepts began to be embraced as superior
and preferred models of thinking and conduct.
Nevertheless, in the modern day, human andenvironmental problems have been blamed, to large
extent, on the anthropocentric worldviews of theWest. This paper explores alternative perspectives
from the Indian tradition to arrest some of these
problems. The East is no stranger to ethics; theIndian (mainly Hinduism, Buddhism and Jainism) andSino (mainly Confucianism and Taoism) traditions
have strived for centuries in the Asian societies. The
paper attempts to show the relevancy of certain
ethical precepts from the Hindu-Buddhist tradition toprovideguidingprinciples
andalternative
explanations on matters that affect humanity and theenvironment
1. Introduction
There is a preconceive notion that bioethics is a
product of Western thinkers, especially stemming out
from the modern philosophers in the likes of Locke,
Kant and others. Their thoughts frame the nature ofsocial, political and ethical dimensions of philosophy
in the modern era, eventually being prescribed as
global values for humankind. Through trading
activities, occupations and later diplomatic relations,Western philosophy and ethics spread rather
aggressively into societies of the East. However, theEast is no alien to philosophy and worldviews either,the Hindu-Buddhist faiths and Confucianism haveexisted in the Asian societies for centuries. Bioethics
principles can be seen in the discourse and teachingof Confucius, Buddha and other Hindu thinkers.
These Eastern discourses are rarely known to theWest. It should be noted that Western prescription ofbioethics is not always congruent with the Eastern
societies. Western constructions of ideas can beproblematic in explaining phenomena in the Easterncultures. The paper attempts to show the relevancy
of certain ethical precepts from the Hindu-Buddhist
tradition in providing guiding principles andalternative explanations on matters that affecthumanity and the environment
2. The Indian Alternatives
Can ethical precepts from the Indian traditions
provide alternative perspectives to addresscontemporary human and environmental problems?
The answer to this question appears to be complex.
This is because the Indian tradition is not free fromproblems concerning humanity. For example, thecaste system practiced by the Hindus for thousandsof years has been blamed for rampant human rights
abuses. In reality, Hindu societies appear to endorsethese abuses as a form of pecking order in societal
hierarchy and classification, which leads to society
imposing different levels of dignity to different groupsof people, usually on the basis of their colour, creed
and professions. As such, it can be argued whether
the Indian tradition can offer any significant
alternatives to address current concerns. Comparedto the West, the Indian tradition has been in
existence longer than any other tradition in the world
and its ethical precepts have evolved over centuries
through dynamic interactions between fellow
religionists, the nature and with other interacting
worldviews. The faith systems, as in the HinduBuddhist belief, are mostly interwoven with societal
values and norms, making it somewhat difficult todifferentiate whether the ethical precepts are faithorigin or cultural-origin. In the Indian tradition,
humanity and human dignity are expressed
differently from the Western tradition. For example, in
the Indian tradition, the sanctity of all form of life andthe preservation of that life is central to the HinduBuddhist belief. This concept is somewhat foreign to
the Western societies, which, in the post industrial
revolution period began to see humans as a factor of
production, with an economic value tag. On thematter of environmental sustainability, ecologicalconsciousness is far more expressed in the Indian
tradition as compared to the West.
The last several decades has witnessed thereemergence of the discourse on human dignity
amongst scholars, analyst and the civil society.
Although the concept had regularly appeared inseveral United Nations documents, especially in the
Universal Declaration of Human Rights (UDHR) andthe European Convention on Human Rights andBiomedicine, it was only recently, after thedeclaration of the Millennium Development Goals(MDGs) and the 1994 United Nations Human
Development (UNDP) report of human security, theconcept took center stage in the thinking of theinternational community. Philosopher, ImmanuelKant (1724–1804) argues that dignity or humandignity is enshrined in the rudiments of humanautonomy. For Kant, dignity falls neatly into an
ethical category, where humans are said to be born
equal in dignity, in spite of their colour, creed andorigin. Kant‟s perspective on human dignity is also
shared by the framers of the UDHR (Miguel, 2004).

Eubios Journal of Asian and International Bioethics 20 (November 2010)
The various principles in UDHR are in actual fact
manifestations of the spirit of human rights, hisdignity and his wellbeing, which also relates to his
environment. In the Hindu-Buddhist tradition, humandignity has a very high priority in the Indian mindset.
Humans are integral to community and therefore
place community interests and wellbeing before
individual-centric egoism. Humans are seen a vital
constituent of family and community, and endowedwith dignity, value and responsibility to safeguard allGod‟s creation. Even though the hierarchical Hindu
caste system has been criticized for a variety ofhuman rights abuses over centuries, Hinduism doprovide elaborate accommodation for human dignity
expression. On the other hand, Buddhism rejects thecaste system and focuses on efforts to liberate
humans from worldly suffering, which is an eventual
consequence of human greed. In Hinduism, somegods are projected in human forms, and Buddhism
claims that humans have the intellectual and spiritualcapacity to achieve superhuman wisdom and release
themselves from the worldly cycle of birth and death(Anonymous, 2002). Human life is sacred and thewhole passage of life is to seek divine truth.
In the Indian tradition human life and other formsof life are considered divine. By putting the divinity
tag, the Hindu-Buddhist faiths place all living beingsin the highest regards. Therefore, hurting or abusing
all forms of life is considered unholy anddisrespectful. This notion is somewhat different in theWestern tradition, which has the tendency to look athuman life and other forms of life for utilitarian andeconomic perspectives. The „soul‟ is integral to theexistence of all life forms, having similar qualities of
the Creator, and thus suggesting that all beings as
divine. Hinduism is also called Sanatana Dharma,
which literally means the „eternal religion‟. It is eternalbecause unlike other religions, there is no specifictime in history to trace its origin and its magnanimous
capacity to embrace the diversities of all otherreligions. The Sanskrit word dharma means bothman‟s nature and his faith. To a Hindu, dharma is the
pursuit towards the fulfillment of the divinity ofhumankind, where we are in inner harmony with theworld where we belong (Chakravarti, 1994). The
concepts of samsara, moksha and karma are also
central to the faiths of the Indian tradition (Hinduism,
Buddhism and Jainism). Samsara is the cycle of birthand death, and as such the very purpose of life is toescape from this cycle of suffering through liberation
or moksha (also called nirvana in Buddhism). Allsouls are said to be reincarnated according to thelaw of karma (which literally translated as theprinciple of cause and effect, action and reaction).
Dead people are usually cremated so that the soul istotally liberated from its previous body (Cordeiro &Ochoa, n.d.). The Indian traditions promote inner
harmony with the surroundings.
Another principle that refers to the inviolability oflife is the concept of ahimsa or non-violence. Ahimsa
promotes sanctity and harmony of life with itself,others and nature (Jayaram, 2010). Humanity is notdevoid of violence behaviours and acts, as history

181

has shown us that humans are capable of creatingharm and destruction to others and the nature.
Violence has become a serious menace worldwide,and continues to devastate lives and societies allover the world. Ahimsa does not refer to nonviolence alone; it also refers to the love for all forms
lives, with no exception made for animals or otherliving beings. This concept claims that all life forms
are divine, whether human or otherwise. Thus, it is
not surprising that the Indian faiths promote
vegetarianism amongst its followers. Nonetheless,the Indian tradition is not free of violence conflicts.
The father of India, Mahatma Gandhi, who is famousfor his pacifism and non-violence resistance against
the British, did not entirely reject violence. Gandhi
claims that “where there is a choice between
cowardice and violence, I would advise violence. But
I believe that non-violence is infinitely superior toviolence.” (as cited in Applebly, 2000). The
Ramayana and Mahabharata have also depictedwars in their texts. These texts have suggested war
only as last resort in the pursuit to defend virtue, after
exhausting all other peaceful means. Even Buddhist
priests have said to have persuaded Emperor Asoka
to relinquish his throne despite his victory in war. The
message here is that waging war may conquer theworld but not the mind and inner peace(Paneerselvam, 2010).
Mahatma Gandhi views ahimsa not merely as apolitical tactic but as an effective way to liberate theIndian people from colonial rule and securing its
national identity. Nevertheless, the strength ofahimsa generates from inner consciousness ofspiritual unity within the people. The Gandhianconcept of non-violence action and satyagraha isincomprehensible if it is viewed as a means ofattaining unity rather than as the ends of inner unity
already attained (Merton, 1964, p.6). Gandhi assertsthat non-violence should be the basic principle
guiding human existence. As such, ahimsa can beutilized as an efficient mechanism for social action
and change, since it coheres with the man‟s intrinsic
nature and the desire for peace, justice, orders,
freedom, and personal dignity. In contrast himsa orviolence devalues and corrupts man, where powerreciprocates power and likewise hatred reciprocates
hatred, thus leading towards humans‟ gradual value
degeneration. In this light, ahimsa has the capacity tocure and restore human nature, bring about social
order and justice. Ahimsa is not an instrument toseize power, but as a means of altering relationshipsthat can bring about harmonious transfer of power.
This is because non-violence is voluntarily acceptedby all parties and has been recognized as a right initself (Merton, 1964, p.23). Human conflicts arosefrom the inability of humans to resolve theirdifferences amicably. As a result, humans may resort
to abrupt and violent responses to manage theirdifferences. The practice of ahimsa provides anatural resource for individuals to address theirdifferences through examining their disputes
collaboratively and seeking harmonious conflict
resolutions approaches. The ahimsa approach may

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Eubios Journal of Asian and International Bioethics 20 (November 2010)provide durable alternative resolution methodology
for much of current day human conflicts.
On the matter of sustainability, Indian tradition has
long embraced ecological friendly values. For
example, the Hindus believe that the material world
may comprise of numerous life forms, but theultimate sustaining force rests wholly on spirituality.
Thus, all forms of life are viewed as divine andhumans are duty bound to protect them. Thispantheistic belief in their value system provides a richresource for the respect for nature. Earth is often
viewed as „mother‟, whilst the mountains as abodesof god and rivers, trees, animals and vegetation as
scared and holy. Humans are integral part of nature,as they are interconnected with other life forms andnon-life forms to form one whole unity. This mindset
promotes sustainable actions, as humans have longco-existed with other life forms on Earth, sharing
scarce resource. The Indian tradition promotes
simple and sustainable ways of living with basic
levels of consumption, without abusing the limited
resources. Equitable sharing forms its core value andthus restraining unlimited individual desires.
Buddhism also advocates its followers to reduce
excessive consumption practices and to adhere to an
ethical lifestyle through basic and simple living, andempathy for the needs of others (Siwatibau Suliana,
2008). The idea of sustainable development entails
the adoption of a sufficiency model, which means
humans should lead a lifestyle that ensures the
succeeding generations will be able sustain a livingwith the same resources. In other words, it promotes
the conservation of natural resources to prevent
further deterioration of the environment.
Elements of nature are often celebrated and evenrevered in the Indian traditions. The forces of nature
have been sanctified in early Hindu scriptures, thus
prompting protection and conservation practices
amongst its followers. The Riga Veda, for example,
the earliest scriptural text of Hinduism, contains
textual hymns glorifying the deities like Agni (Fire),
Indra (Storm & Rainfall), Surya (Sun), Soma (Moon)
and Usha (Dawn) (Nevatia, 2006). Mahatma Gandhi
also spoke about environmental sustainability. He
argued that there are no limits to the desire ofhumans, and arbitrary quests for achievement andsatisfaction have brought about environmental
degradation in the West. Gandhi makes a clear
distinction between the concepts of „needs‟ and„wants‟ in explaining human nature. For him, „needs‟
refer to the fulfillment of basic requirements of life,
which is to survive and grow. Meanwhile, „wants‟ isthe human wish to fulfill desires. Several decadesago, Mahatma Gandhi warned Indian not to imitate
the living standards of the West. He claimed that the
scarceresourcesofIndia
simply cannot
accommodate India‟s large populace if they decide toconsume and live like the Westerners. It should be
noted that his warnings are still relevant to thepresent day consumerist culture and waste-centricsociety (Pravin Sheth, n.d.). He also advised thepresent generation to take on the responsibility to
use the resources succinctly, while considering theneeds of the future generations who will inhibit thesame mother Earth. This idea is embedded in thenotion of trusteeship ethics. Humans have the sacred
duty to safeguard nature not only for their own use
but also for future generations. Gandhi‟s popular
quote, “the Earth has enough to satisfy the need of
all the people, but not for satisfying the greed ofsome,” will be of significant relevance incontemporary
discourseonenvironment,sustainability and climate change.
3. Conclusion
Can Indian tradition suggest alternatives principles
to guide humans in dealing with other humans, otherspecies and his environment? While it is difficult toprovide an outright answer, it will be pertinent to notethat in addressing current day problems, as argued
earlier, Western precepts have failed to provide
meaningful solutions to many of these problems.
However, it will be erroneous to suggest that all fromthe East is good and all in the West is bad, as
principles such as love, compassion, nobility andduty exist in all cultures in spite of geographical,
political and religious differences. Nonetheless, assuggested earlier, Indian precepts can offer somemeaningful alternative perspectives in addressing thesaid issues and dilemmas.
The principle of collectivism is one of the central
themes of the Indian tradition. It encourages
unselfish attitudes towards oneself, others andnature, and thus instilling the understanding that
oneself is essentially a part of a bigger whole,
Therefore, one‟s actions ought to be mutuallydependent and harmonious to the interests of others.
Such values are often lacking in Western ways ofthinking. The principle of non-violence is a centralprinciple of the Indian thinking. This principle
promotes harmonious and peaceful co-existence withall beings, the nature and the universe. Nature is vitalfor the existence of species, and without it, there will
be no life on earth. Therefore, safeguarding theenvironment for present and future use becomes thecentral responsibility of humans. The Indian tradition
ethical principles can offer alternatives but it requires
rethinking and embracing of new sets values.
4. References
1. Anonymous. (2002). Hinduism and Buddhism. A
Comparison. Retrieved 27 July 2010, fromhttp://sc.essortment.com/hinduismandbud_rtqs.htm
2. Applebly, R. S. (2000). The Ambivalence of the sacred.
In R.S. Appleby. The ambivalence of the sacred:religion, violence, and reconciliation. (The Sacred and
The Sovereign, University of Chicago). Lanham, MD:
Rowman & Littlefield. Retrieved 20 August 2010, fromhttp://sacred-sovereign.uchicago.edu/rsaambivalence.html
3. Chakravarti, S.S. (1994). Hinduism: A way of life. [ebook] Delhi: Motilal Banarsidass. p.23-24. Retrieved 23
August2010,from
http://books.google.com.my/books?id=J_rASTgw8wC&printsec=frontcover&dq=Chakravarti,+S+
S.,+Hinduism+A+Way+of+Life.&source=bl&ots=lDcIx_
Sn6X&sig=qp1F8zjWP9NUEDNYQ_K3UJ7vRkM&hl=e
n&ei=gzOETMiSA5HGvQO4soGUBA&sa=X&oi=book_r
esult&ct=result&resnum=1&ved=0CBYQ6AEwAA#v=on
epage&q&f=false

Eubios Journal of Asian and International Bioethics 20 (November 2010)
4. Cordeiro, J. and Ochoa, S. (n.d.). Religion, science andimmortality. Retrieved 21 August 2010, fromhttp://www.transhumanism.org/tv/2004/Cordeiro.pdf
5. Jayaram, V. (2010).The concepts of Ahimsa or nonviolence.
Retrieved
23
August2010,from
http://www.hinduwebsite.com/hinduism/concepts/ahims
a.asp
6. Merton, T. ed. (1964). Gandhi on non-violence: aselection from the writings of Mahatma Gandhi, New
York: New Directions.
7. Miguel, C.R.( 2004). Human dignity: History of an Idea ,Dictionary of the History of Ideas, [online] 28
September 2004, p.3–14, Retrieved 26 July 2010, fromhttp://etext.lib.virginia.edu/cgi-local/DHI/dhi.cgi?id=dv4–20
8. Nevatia, H (2006). Hinduism and the environment: The
Pagan element in Hinduism advocated sustainable
development as evidenced in The Riga Veda and The
Bhagavata Purana, (update 14 Oct 2006). Retrieved 20
August2010,from
http://hinduism.suite101.com/article.cfm/hinduism___su
stainable_development
9. Paneerselvam, S. (2010).The use of non-violence in
war and peace. In D. R.J. Macer and Souria Saad- Zoy(Eds.). Asian-Arab philosophical dialogues on war andpeace. Bangkok: UNESCO.
10. Pravin Sheth (n.d.) The Eco-Gandhi and ecologicalmovements. Retrieved
3 August 2010, fromhttp://www.gandhimuseum.org/sarvodaya/articles/ecog
andhi.htm
11. Siwatibau Suliana (2008). Ethical dimension for sustain
our environment: A Pacific island perspective. In D. R.J.
Macer (ed.). Asia Pacific perspectives on environmental
ethics. Bangkok: UNESCO.

The Winter of Clinic?
Advanced EthicalDilemmas for an Advanced
Medicine- Paolo Cattorini, Ph.D.
Full Chair Professor of Bioethics, State University ofInsubria, Varese, Italy; former member, National
Committee for Bioethics (Rome) and National Commission
for the Fight against Aids (Rome)
Email: paolo.cattorini@uninsubria.it

Abstract
Scholars in narrative bioethics, all over the world,
are confronting some key questions. Which medicine
will survive? What kind of promise, of covenant, ofalliance will be signed between the professional
power and the society? Three controversial ethicalissues, among others, stir the debate: persistentvegetative states, artificial procreation, individual
requests for reshaping an healthy body (doping
included). Dealing with these dilemmas, typical ofadvanced medical science and technologicalpractice, implies not only balancing carefully theburdens and benefits (in an utilitarian way) forsuffering persons, families, equipment, hospitals,
cultural and religious communities, but also imaging
and realizing new visions of a just society, of a183

beneficent (without paternalism) medicine andgenerally of a good life, where each moral agent
could write in worthy and convincing ways the next
chapter of the book of his/her own life. Both literary
tools and intellectual concepts give resources to thesame intriguing research.
Winter, snows and cultural death
A suffering man. A frightened woman, unable tohelp him. And above all, the snows of Kilimanjaro.
The Snows of Kilimanjaro is the famous novel by
2Ernest Hemingway and an eloquent metaphor of the
doubtful identity of the healing professions, whichmake diagnose much more than they can cure, andwhose social aims are largely confused andsometimes
expressedinembarrassing,
contradictory, illusory promises.
“The marvellous thing is that it‟s painless,” hesaid.
“That‟s how you know when it starts”.
“Is it really?”“Absolutely. I‟m awfully sorry about the odour,though. That must bother you”.
“Don‟t! Please don‟t.” […]“Please tell me what I can do. There must be
something I can do.”“You can take the leg off and that might stop it,though I doubt it. Or you can shoot me. You are agood shot now. I taught you to shoot didn‟t I?”“Please don‟t talk that way. Couldn‟t I read toyou?”“Read what?”
Reading something. The value of narrative in
medicine (the so called narrative medicine) and in
ethics (the stream of narrative ethics) might offer asafety anchor for scholars reflecting upon the futurerole of biomedical practice. That‟s what we are going
to explore in the next pages.
Visions of medicine
What will be the Hippocratic heritage in this new
3century ? Which moral dilemmas will provoke that
legacy and challenge its primary duty of beneficence:to act in the interest of the patient, by preventing
harm, promoting good, removing evil? This article
tries to underline three problematic areas and sometheoretical issues at stake. The main thesis, wedefend, is that we need to rebuild medical ethics,
4
beyond the so called “principlism” , taking in account2

Ital. transl. Le nevi del Kilimangiaro, Milano, Mondadori,
1992.
3
This article extends the text sent in 2009 to an Italian
Journal, Medicina nei Secoli - Journal of History ofMedicine (Rome), with the title “Shall I become a Zombie?
Storied of Illness, Ethical Dilemmas and Visions ofSociety”, by mantaining the previous structure, and simply
adding some new comments and literary references. Our
aim is to analyze and compare the reactions by readersbelonging to a wider, Asian and international context. We
thank the Direction of Medicina nei Secoli, who gave thepermission.
4
The famous book Principles of Biomedical Ethics, by T.L.
Beauchamp and J.F. Childress, Oxford, Oxford Univ.
Press, 1979, 2001 (5th ed.), has raised several

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

the role of emotions, of moral symbols and leading
narratives. Narrative ethics is not the trendy hobby ofsome tired moral philosophers, but it represents theperennial dimension of Western thought, since its
Socratic beginning.
The analysis of important moral dilemmas (as theones presented in the following pages) will show theimportance of an interdisciplinary, pluralistic andsocially constructive dialogue and it will display the
key role of the ethical evaluation, that is the effort torationally justify hard decisions in health care policy
and at the patient‟s bedside. In this reflective work,
visions - as we have said - play a crucial role. As thephilosopher Plato has explained once and for all, themyths are not the tomb, but rather the ground of thereason. Philosophical and especially ethicalinterpretations have in mythos and logos their systoleand diastole, the double wing of the same passionate
search for truth. Logos critically reflects upon the
mythos, which we believe in, and reshapes suchnarratives, but in no way it can replace or get rid ofthem. The truth-search, we have mentioned, takes
each time the form of thinking by means of concepts(theories) or by means of images (metaphors, tales).
To decide the right way of dying, of procreating, ofpracticing medicine, we need not only a logicallycoherent use of intellectual concepts, but also a
convincing, enchanting, promising and leading visionof a good personal and societal life. As Karl Jaspers
has written, any world-vision has an objective side(the world-image) and a subjective one (the attitude
toward the world).
At the beginning of life
The topic of assisted procreation produced acultural turmoil in Italian society, since a very
restricted law has been approved by the Parliamentin 2004. The prohibition of gamete donation, ofembryo freezing and of preimplantation genetic
diagnosis, prompted libertarian associations todemand a public referendum in order to amend thelaw. The referendum took place but did not reach thequorum required to be effective. In the meantime, theSupreme Court named Corte Costituzionale has
declared unconstitutional some important articles, sothat a deep fissure is impairing the law‟s application.
Beyond the result, what astonished anddisappointed several expert of bioethics was theatmosphere and style of the debate: wall against
wall, slogan against slogan, parody of adverse
positions. A grotesque tug-of-war was played
between some embryo life defenders and procreative
rights supporters. A liberal Catholic standpoint likemine was widely ruled out and obscured. The mostamazing show was the recourse to embryologists in
television talk programmes: some of them claimed todemonstrate or exclude the personal identity of thezygote on a mere genetic or biological basis, without
analysing the philosophical dimensions of the terms(such as individual) they used.
disappointments over the last years. See for example
E.R.DuBose-R.Hamel-L.J.O‟Connell, Eds., A Matter ofPrinciples? Ferment in U.S. Bioethics, Valley Forge, Trinity
Press Int., 1994.

Not to imitate this simplistic fight, advanced ethicalissue, as the one regarding the nature of embryo,has to be dealt with a more correct interdisciplinary
approach. Neither embryologists alone nor
philosophers or theologians alone can solve, andeven understand a question like that: “is an embryo aperson?”. The reason is that in the same sentence
two terms appear, belonging to different disciplines:
embryologists know well what can be seen at a
microscope in the phase of morula, but they ignore
what the word person means (and usually nobiological handbook offers a definition). Person isindeed a classic key word of philosophy andtheology, but their initiates don‟t have conceptual
tools by themselves, if they do not previously attend
biomedical lessons, to deal with the scientific side of
the issue, for example to explain which are theunifying/growing factors of an human fertilized egg.
Interdisciplinarity, one essential feature of5bioethics , implies that different disciplines should sit
at the same table, dialogue each other, mutuallytranslate their languages, look for bridge-concepts(the concept of individual, for example, in the case ofembryo debate), which enable a cognitive exchange.
In the next years, it will be more and more importantthe effort to interpret another science or practice fromour own disciplinary point of view, and, reciprocally,
to let another scholar to read our data from his/herown perspective and to force us to rethink ourconclusions in the light of discoveries made within
another scientific domain. Neurosciences and“neuroethics” could be an excellent test bench of thischallenge. Interdisciplinarity is a more difficult
enterprise than multidisciplinarity, that simply collectthe different perspectives, coming from multiple pointof view, which regard the same complex object ofstudy.
Another essential methodological premise for
dealing with ethical dilemmas is taking seriously thepluralistic arena that we live and work in. As in thecase of procreation law, it may happen that almost all
the citizens see the necessity of a law, to avoid theso called “tube-babies Far West”, but their opinions
diverge about the legal contents: admitting or
prohibiting insemination from donors, surrogate
motherhood, embryo selection and so on. If a debate
becomes a war based on the principle “nothing orall”, whoever wins (libertarian of conservative wings)
will prevent the losers from following coherently theirmoral supreme values in such an intimate andprivate field like the procreative decision. The
minority opinion, not being legally recognized at all in
its requests, will suffer a deep wound (whose
consequences are likely to disturb and hinder the
future dialogue on similar topics), and it will be
tempted to sabotage the implementation of the bill, toconceal forbidden behaviours or to find alternative
solution, like procreative tourism. Even for people
believing in a universally knowable ethical truth,
pluralism nay be a positive condition to foster
dialogue and to deepen one‟s own position. Pluralism
does not necessarily lead to the heavy, paralysing5

See our book Bioetica. Metodo ed elementi di base peraffrontare problemi clinici, Milano, Elsevier, 3rd Ed., 2006.

Eubios Journal of Asian and International Bioethics 20 (November 2010)
consequences of the extreme skepticism or6
relativism , which affirm that moral values are nothing
but the private, unquestionable expressions ofemotional drives, that are disconnected from rational
reasoning.
Now, if a mature society liked to frame common
criteria for promulgating a new law in a controversial
matter,itshouldabandonfanatical
andfundamentalist hypothesis and ask each “thinkingfamily” to rank the priority of its own moral points, by
distinguishing what can‟t be renounced (its moral“core”) from those demands that might be negotiatedor even delayed and postponed. In Italian law, theCatholic position, in some way, has prevailed, but, asa Catholic thinker, I have been asking the following
question: what would happen if my religion were7
minority in a Huxley‟s State , where only extreme
forms of artificial reproduction took place, and if theright of naturally procreating within an religious
heterosexual marriage were neglected or fought?
Wouldn‟t we Christian families oppose such a law?
Wouldn‟t we ask an abrogative referendum?
Wouldn‟t we judge as an unfair offense the decisionof the presumed majority not to partecipate in thevote and to recommand the abstension? The Italianresults of the wrong strategy of inviting to escape thepolls are serious: a bargaining atmosphere has beendarkened and we still don‟t know if the greater part ofItalian people actually favour the present law in aconvinced and informed way. In fact, in the large
portion of abstentionists there have been also lazy,
misinformed, indifferent citizens. The hypothesis of a“veil of ignorance” should work in moulding our future
laws: if you don‟t know who will win the election, what
do you think it is right to previously agree with your8
opponents ?
As you see, dealing with this kind of problems
entails not only that we deepen our personal ethicalposition, but also that we image and trust a vision ofa just society, where minorities and vulnerable
people rights are protected, and where - at the sametime - conditions are set for an open, transparent,
respectful debate, in the hope that the best solution
will persuade reluctant interlocutors, instead of
imposing them heavy forms of veto. An example
concerns our position. A religious person, who ismorally against in vitro fertilization from donor (for thereason that a stranger gets in an intimate loving storyof a couple, gives birth to someone, and thencompletely disappears without bearing any
responsibility for what has happened), might
nevertheless oppose a prohibitionist law. We have
got no sociological evidence that children born from6

See this distinction in S. Veca, Etica e verità. Saggi
brevi, Fondaz. Europea G. Venosta – G. Casagrande
Publ., Milano- Lugano, 2009, p. 37
7
A. Huxley, Brave New World, 1932; Id., Brave New
World Rivisited, 1958 (Ital. transl.: Milano, Mondadori,1971).
8
I have in mind for example the precious ethicalexperiment outlined by R. A. McCormick, "Abortion: theunexplored middle ground", Second Opinion, 10, March
1989, pp. 41-50.

185

an heterologous insemination suffer severe mental
disorders or that family institutions are destroyed.
Therefore, at least one kind of Christian position
could limit to bet that its vision of a worthy “coming
into the world” would convince, day by day, social
experiment after social experiment, the supporters ofa different cause. Generally speaking, moral
traditions have to put themselves to the test of the
new technological alternatives and historical choices,
just to know in which sense their ethical heritage isstill rich of fruitful perspectives.
At the end of life
A common front, established among secular andreligious moral traditions, can oppose - we hope medical overtreatment, improve advance directives,
prevent paternalistic attitudes, implement hospicesolutions for poor and lonely terminal patients,
defend terminal palliative sedation. But an hard pointof disagreement remains and it regards ill persons inpersistent vegetative state (PVS), that we define, inthe context of this article and for the benefit of aclearer discussion, as the condition where noawareness (no sentience, no feeling of pleasure,pain, thirst, hunger and so on) is anymore possibile,
forever.
We would like to ask ourselves: is it possibile,even in this topic, to follow the recommendation by
the Italian Conference of Bishops, Communicating
the Gospel in a Changing World, June 2001, when
they remember that non believers might havesomething to teach us believers, regarding theunderstanding of life, so that, in unexpected ways,
the Lord can make His voice be heard thanks to9them ?
Some ethical agencies affirm that artificial nutritionand hydration (AHN) are always morally
proportionate and ordinary (in the sense that it ismorally wrong to withdraw or withhold them), if they
produce the foreseen nutritional results, if economic
resources exist and if no adverse effect or physicalinconvenience arise. This is also the conclusion of
the Congregation for the Doctrine of Faith,
responding (on Aug. 1, 2007) to some U.S. Bishops‟
questions. Even if this position underlines correctly apresumption in favour of life, defends the personaldignity of disabled patients, recommands a justallocation of resources for ill persons and theirfamilies, and gives voice to the weakest members of
our human family, its peremptory style and brief final
statements have caused some perplexities in several
10
ethicists. We summarize here the main critiques .
First of all, it is impossibile to ethically evaluate amoral action, without taking in account its meaningand such a meaning can be understood only within ahuman story, the story of a moral agent with his/hervalues, feelings, style of living, relationships, ideas of9

See p. 28.
The literary genre itself of the Document hasn‟t beenquite helpful in order to deepen the ethical reasoning. See
our Editorial “La professione medica oggi. Dilemmi etici”,
in the Journal Riv. Ital. Med. Leg., 2008, n.6, pp. 12051225.
10

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Eubios Journal of Asian and International Bioethics 20 (November 2010)11

beauty, vision of a good life . Precedent events,
consequences, cultural background, subjective
affections and intentions, all this cluster ofingredients make up the context, that guarantees afaithful interpretation of the text, represented by each12
human deed
. The same kind of action, as
described from an external, detached and impersonal
point of view, might have different and even opposite
meanings, if it is seen in the concrete light ofspecifically different situations and stories. Meaning
depends on stories, stories depend on characters,
and characters are defined by the promises they
make to themselves and to others.
Now, PVS is a tremendously new condition,
usually created in the last decades by intensive careunit, a condition that legitimately receives different
interpretations and therefore reveals different
meanings. Some people would like to be indefinitely
sustained by ANH, if they fell in PVS, because theyrecognize this condition as not particularly repugnant,but rather an amplified, extreme figure of the
weakness and dependency, that mark every limited
human life and that needs an adequate respect,care, attention by the entourage. Other people, who
treat as well patients in PVS as living persons,having the same right to care of every other patient,
think notwithstanding of this condition as a painlesstorture, an artificial stop of the dying process (caused
by a severe encephalic injury), an invisible prison, adefacement of personal dignity, an exile in which aperson is confined, without the possibility of evenexpressing the primary message “please let me go”.
Let me go, let me die. This last position - we think can be rightfully taken also by Christian and even
Catholic believers, because it is not equivalent to asuicidal attitude. They rather make a discernmentand consequently balance benefits and burdens of
the life sustaing treatments, to conclude (signing a
specific advance directive) that their life has not to be
prolonged at any cost, not at the cost of this kind of
survival. As you know, in Christian moral tradition, life
is a fundamental, basic, but not a supreme orabsolute value, so that the main duty is living a goodlife (good in a Christian sense) and not expanding it
as more as possible. Life has rather to be spent forjust causes and in the effort of achieving supreme
values, even if that implies putting life at risk. This is11

For the notions of biographical unity and vision of agood life see A.C. MacIntyre, After Virtue. A Study inMoral Theory, Notre Dame, Univ. Notre Dame Press,
1981. We have rethought this book referring to end-of-lifeclinical cases in P. Cattorini, La morte offesa.
Espropriazione del morire ed etica dela resistenza al male,
Bologna, Dehoniane, (2nd ed. with a new Afterword),
2007. For the problem of PVS see: P. Cattorini-M.
Reichlin, “Introduction”, e “Persistent Vegetative State: A
Presumption to Treat”, in Theoretical Medicine, Issue on“Decisions of Medicine at the End of Life” edited by P.
Cattorini – M. Reichlin, v.18, n.3, Sept. 1997, pp.217-219,
263-281.
12
For the notion of action as a text, see Paul Ricoeur‟sphilosophical researches, for example P. Ricoeur, Soimême comme un autre, Paris, Seuil, 1990; Ital. transl. Sècome un altro, Milano, Jaca Book, 1993.

the only way of honouring and not morally
impoverishing its dignity.
“In numerous cases, the complexity of thesituation can be such as to cause doubts about theway ethical principles should be applied. In the final
analysis, it pertains to the conscience either of thesick person, or of those qualified to speak in the sickperson’s name, or of the doctors, to decide, in thelight of moral obligations and of the various aspects
13of the case.”
If we don‟t recognize and respect both thesedifferent personal evaluations of ANH in PVS, we
stifle one original vision of world and suffocate one
kind of religious spirituality. It is not an overtreatment
if we sustain for years and years people who need
14
and want ANH and it is not a passive euthanasia
stopping such a treatment, if the patient had
beforehand requested it in an informed, free andcompetent act of will, and if the society has freely
offered all the services and resources needed in bothcases.
Unfortunately, the “winter of clinic” (in the sensethat clinicians surrender to the technical injunction to
repair the broken gear) ties up with neo-paternalism,
by expropriating moral autonomy. It is an amazing
vice to shift from a personal dimension to aprofessional one, giving the physicians the last wordin the matter, and asking healthcare professionals todecide if a treatment (in this cas ANH) is or not a
proportionate one. The only thing that a technician
may evaluate is the efficacy of a therapeutic mean,that is the capacity to obtain some biological results.
But when we use the term “proportionate” (anaesthetic term, one of the classic necessary featuresof a beautiful work of art), it means the congruity, thefitness, the harmony existing between that form ofcare and the human world, the personal values, theexistential style of a patient. It is neither a physicalnor a psychological matter: it is an ethical one, andno technical expertise or scientific knowledge could
transform a doctor in a moral judge. If this shortcircuit
sometimes happens, due to social or ideologicalpressures or to professional arrogance, technicians
usually cast their moral shadow in the bedsidesituation and substitute their own ethical stance forthe patient‟s one.
We deeply worsen the quality of reasoning if we
define ANH not a medical treatment but a daily,
15
elementary form of caring. If you attend a
symposium about artificial nutrition (a kind oftreatment originally thought to aid transient digestive
diseases), you have to realize that an entire staff oftechnical competences is needed (surgeon, internist,
gastroscopist, nutritionist, specialized nurses and soon) to position, control, monitor and periodically13

Sacred Congregation for the Doctrine of the Faith,
Declaration on Euthanasia, Vatican City, 1980, pp. 9-10.
14
Catholic moral tradition condemns both active andpassive euthanasia, as they are both seen as forms ofrational assisted suicide.
15
Against the thesis affirmed by the “Position of theAmerican Academy of Neurology on Certain Aspects of
the Care and Management of the PVS”, Neurology,
XXXIX, 1989, pp. 125-126.

Eubios Journal of Asian and International Bioethics 20 (November 2010)

187

evaluate the efficiency of the device and its biologicalconsequences. Relatives or friends of the patient
may learn and implement some manoeuvres (as it
happens also for artificial ventilation at home), but
the methodology needs a technological leadershipand responsibility. It is something completely
different from keeping a body warm, clean and dry orfrom making sweetly a bed. The term “elementary”
itself has several meanings: elementary for whom?
Compared to what? At which level? And for what
reasons? One boy may find it elementary to learn
tennis, another may find terribly difficult to hold theracket.
As we have shown in other texts, metaphors andnarratives interweave ethical and even clinical16
reasoning . Then it does not astonish us thatrhetorical figures connote both daily and scientificdiscourses. But this dimension has to be criticallyanalyzed, not to become a subtle form of
propaganda. “Giving water and food” or “offeringsomebody something to drink and eat” is quite
diverse from artificially nourishing a comatose
patient. Daily language words are stripped out fromtheir authentic use and twisted to normalize
something that is morally controversial. This linguistic
tactics hides an ethical evaluation, that rather would
deserve to be rationally justified and debated.
“Eating” is voluntarily putting something in our mouth,
tasting and usually enjoying it, chewing andswallowing it, and then feeling a sense of satiety.
“Giving something to eat” usually means helping
someone to make such an experience, filled withperceivable psychological, cultural and moral
significance. Is this what happen in ANH? We
understand the usual ethical importance of feeding
someone, that is expressing, in an elementary way,
the respect and care we owe to every member of oursociety, especially to the weakest and mostvulnerable ones. But this respect, not to fall into apaternalistic bias, has to be thought and revealed
through the interpretation of the meaning of theaction, and some people, who thank anyhow thesocial helpfulness shown toward them (the readinessto hydrate them with devotion and skill), have theright to tell anyone in advance that they consider awrong decision the choice of prolonging artificiallyand endlessly a sort of “dreamles sleeping”.
Caressing a child is normally a tender act, but insome situations and for some children it might soundas a dangerous omen of violence.
Finally, it is bizarre to redefine these life sustaining
procedures as “natural” instead of “artificial”, statingthat they would guarantee the normal alimentaryneeds, by giving stability to the nutritional functioningof a non terminal patient. If “natural” is used in a
medical sense, it sharply contrasts the scientificconsensus statements, that actually talk of “artificial”
17
18
NH . If “natural” is used in a prescriptive sense , it
presupposes the ethical conclusion that rather shouldstill be demonstrated: the conclusion that is always amoral duty prolonging ANH in PVS. In this casesome ethical questions have to be raised: why sucha primary importance is given to the digestivesystem? Its functioning is of course essential for life,
but the same thing could be said of the respiratory,
cardiac or urinary systems. In the condition of PVS,
should all these biological systems, in case of theirfailure, be indefinitely replaced by artificial devices(artificial ventilation, dialysis, and so on), for thereason that the patient is not strictly terminal (in thesense that his life may go on, if medically assisted)?
Wouldn‟t this attitude lead us to the so called
technological imperative: “apply any available
technological resource to keep life at any cost!”, an
imperative that sounds terrifying even in a science
fiction tale? Furthermore, if the word “natural” or“normal” is identified with “proportionate” (in thesense that ANH reach its biological aim), you giverise to an ethical misunderstanding, because theproportionality of a treatment has not to be referredto the homeostasis of the living organism and it is notmeasured with reference to the hydrosalty
equilibrium, but to the global interest of a person,with his/her values, beliefs and preferences. It would
be “unnatural” and “abnormal” ignoring thisanthropological dimension.
Instead of building rigid decision-charts, hard
medical dilemmas have to be prepared through anadvanced, informed, competent and non-directive
communication, that takes in account the critical,
general interest of a person, who is shooting (in thesense of cinema) something like the final sequenceof the precious film of his/her life, looking for an
19
happy, just and worthy end . Such a dialogue might
be improved by the presence of an ethics consultant,
not to deprive patients, families, health operators andpsychologists of their voices and responsibilities, but
to facilitate the interdisciplinary debate and deepen
the ethical nuances of the decision. Consultation is a
frontier-land, at least in our European Countries, andsometimes it is burdened by vices and naivetè, but
the challenge has to be taken up, not to leave thematter in the hands of charlatans, of frauds,
uninformed dogmatizers, or of primitive and savage
20
moral gamblers .

16

17

P. Cattorini, Un buon racconto. Etica, teologia,
narrazione, Bologna, Dehoniane, 2008. See also ourarticles: “The Desire for Children and the Experience ofIllness. A Christian Ethical Perspective, I supplementi diTumori, v.3, n.3, S171-S175, 2004; “Narrating Pain: The
Role of Medical Humanities”, Eubios Journal of Asian andInternational Bioethics, v. 16 (6), Nov. 2006, pp. 177-181;“Aesthetics in Ethics: Narrative and Theoretical
Dimensions of Moral Evaluation”, Eubios. Journal of Asianand International Bioethics, 19, March 2009, pp. 47-53.

To deepen these aspects, read C. Tollefsen, Ed.,
Artificial Nutrition and Hydration. The New Catholic
Debate, Springer, Dordrecht, 2008.
18
In a descriptive sense, it merely means that a event
usually (ut in pluribus, in Latin words) happens.
19
See. R. Dworkin, Life’s Dominion. An Argument about
Abortion, Euthanasia, and Individual Freedom, 1993 (Ital.
transl. Il dominio della vita, Milano, Ed. Comunità, 1994).
20
P. Cattorini, Bioetica clinica e consulenza filosofica,
Milano, Apogeo, 2008.

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

Reshaping the body
Another important issue, which ethics in advanced
medicine deals with, refers to the aims, scopes and21
limits of medicine . Waiting? Or shooting thepatient? Or taking the leg off? – to use Hemingway‟s
words. Medicine has become a sort of secularreligion and questions, that traditionally had beenaddressed to priests or philosophers, are now thematter of medical or psychotherapeutic decisions. At
the same time, ethics (generally, the philosophicalconsultation movement) is fortunately regainingsome of what has been expropriated by science, but
the fight for independency is quite hard and somepeople have difficulty in understanding the difference
between how questions (how to manage thisdisease? how prolonging the life? how in vitro
inseminating an infertile woman?), and whyquestions (why looking for a delayed but worse
death? what is the moral meaning in generating achild? why telling patients the truth?). With theexcited complicity of some pharmaceutical market, ofpowerful health care institutions and of celebrated
specialists, medical knowledge has settled regions oflife and of ordinary experience, that common people
were used to live, handle, share and administer with
their own wisdom, practical skill and mutual
cooperation.
One of the most impressive example of “cultural
22
iatrogenesis”, to use Illich‟s words , is the palliative
myth, the illusion of a pain free world and of asuffering free life, under the governance ofanaesthesia vestals, who declare pointless bearing
with full awareness the pain and living crisis
situations, instead of taking off consciousness by
artificial means. Fostering the moral strength to keepown‟s one feeling power, in spite of pain and throughsuffering phases, is deemed a primitive, out offashion, foolish masochism, when sedative medical
devices are available (drugs, Caesarean sectiondelivery, epidural anaesthesia, and so on). Beyond
what line technical progress becomes a tempting,unreasonable fashion?
What scope the medicine should have? Our
opinion is quite simple: it is properly medicine every
act who tries to heal a sick person, using scientificcompetence, technical skills and/or empiricalknowdledge. The reason is that, in our philosophy of
medicine, the core of medicine is the clinic, that is themoral enterprise of caring for an ill person. In thissense medicine is not, first of all, an applied science,but a covenant between a suffering person and acaring expert (an individual or a team): two allies who
decide how much knowing and doing for the benefitof the weaker. As you can see, the heart of thematter is the intention, along the Hippocratic tradition

21

A famous international Report by Hastings Center isdevoted to the issue. We have read it in the Italiantranslation “Gli scopi della medicina: nuove priorità”,
appeared in Notizie di Politeia (Milan), 13, n.45, 1997.
22
I. Illich, Limits to Medicine – Medical Nemesis: theExpropriation of Health, London, Marion Boyars Publ.,
1976.

23

(but avoiding any past paternalism ) of healing thesick, in the different directions that the purpose of
beneficence can take: to cure, to care for, to sedate,to prevent, to rehabilitate someone who suffers for an
illness. The clinic is the core, but it seems to be in
winter, hidden by the snow of controversy. Let‟s draw
the consequences of our thesis.
What exceeds the caring field does not deserve, ina strict sense, the title of medicine, even if it
possesses some material elements belonging to
medicine: technological competences, for example,
or scientific doctrine. If an unjust government causessocial malaise, this is not a medical problem (theideological use of psychiatry in totalitarian regimes
was unfortunately an eloquent example of thisconfusion). If a technically skilful dentist drills theteeth of a marathon man (as in the movie picture
directed by Schlesinger in 1976) not to cure his
caries, but to torture him in order to obtain some
information regarding diamonds, that dentist is notpracticing medicine, but simply making use of
medical expertise. Another instance: some kind of
aesthetic surgery (the Hastings Report says) are non
medical, but socially acceptable use of medical
knowledge. Take for example a television star, whoasks for a surgical intervention of breast reshaping,neither because of some somatic disease nor anxiety
disorders, but - she confesses - because she needs
new contracts and her beautiful and healthy breast
forms are out of fashion. Well, this desire (from ourpoint of view) is not a medical need and a physician
should decline, on principle and generally speaking,to satisfy the request.
The same thing might be maintained about
granting the demand of a body artist, who needs anabdominal incision for his next performance: a public
exhibition in a well known museum. Not even thedesire of a deep, invasive piercing can justify amedical intervention. The physicians‟ duties are not
to make everything that might have serious
psychophysical consequences, if it is done by anincompetent layman (like a piercing inserted in septic
and antihygienic manners), but to follow the social
promise of acting in the interest of the patients, andnot to serve other aims: economical, scientific,
political or whatever else. This is the basis of abeneficent profession and of its code of ethics. On
the contrary, if advanced society needs a technician,ready to fulfil every desire formulated by informed,
free, competent, paying clients or by customers
associations, then medical schools will have tocreate (besides the traditional figure of physician) a
second kind of profession, free from HippocraticOaths and from ethical boundaries. We suggest tocall iatrotechnicians these new kinds of bodyrebuilders.
In the first legal trial, where I have been invited, as
an ethicist, to act in front of an Italian Court as anexpert appointed by the lawyer for the defence, theprosecutor asked the conviction of an African woman
for complicity in abuse of medical profession. The
woman was a Catholic one, but she wanted her son
23

E.D. Pellegrino – D.C. Thomasma, For the Patient’s
Good, New York, Oxford Univ. Press, 1988.

Eubios Journal of Asian and International Bioethics 20 (November 2010)
be circumcised, one month after his birth, for ethnicalreasons, as a sign of their cultural and geographic
origin. Such a practice was still quite common, andeven known and tolerated by the Catholic priest, an
African himself, pastor of that Afro-Italian spiritualcommunity. Unfortunately something went wrong:
another woman, a friend of the mother, who wasused to make this kind of interventions in a private
flat and in hidden ways, made the child bleeding. He
was brought to an emergency department and thevisiting doctor reported the fact to the police. The
public defender (the mother had no money for private
lawyers) asked my help because he found out that,some years before, I had written an opinion dissent
in a statement by the Italian Committee for24
Bioethics .
My dissent was quite simple: a religious male25
circumcision is not justified on a clinical basis , but
on ritual grounds. Therefore the intention is not atherapeutic one and the act doesn‟t deserve the labelof “medical” in the strict sense we have explained
above. In other words, I cannot see ethical reason toqualify as clinical intervention a religious act thatgenerates a (even though little) physical breach,generally produces some discomfort in the child andleaves indelible and irreversible bodily marks (I‟mtranslating some Committee Document‟s terms),
even if no impairment of sexual and reproductivefunctions is created. An act, I would like to add, that
obviously cannot be approved by the informed
consent of the (under age) citizen involved.
Moreover, I can see no substantial difference
between religious, ethnical or simply private bodily
injuries (“private” means: based on the individual,
secular value preference of someone). To avoid any
sort of discrimination, the consequence of our pointof view is that no physician (working in public or
private institution: it doesn‟t make difference) has aduty to perform such kind of gestures. What‟s more,
an health care professional should not violate thesocial promise, that he will act only for the good of ill
24

Comitato Nazionale per la Bioetica (CNB) (Roma), La
circoncisione: problemi bioetici, Sept. 25, 1998,
Presidence of Council of Ministers. Beyond my dissent,
within the Committe the positions were not unanimous. All
the experts condemned female infibulations, but for somemembers, the male religious (ritual) circumcision in a
newborn (usually Jewish children are circumcised at the
8th day; later on for Islamic ones), could be made byreligious ministers specialized in the practice and having
trained an appropriate and acknowledged competence(even if they are not health care professionals), because
the intervention is deemed quite simple. The ministers
should also warrant the assistance that might become
necessary, if something goes wrong after the rite. The
reason of this tolerance is expressed in the Document:
those members evaluated as inopportune themedicalization of religious practices. I completely agreewith this concern. These paragraphs are nothing but theparaphrase (translated in English) of my disagreement.
25
The premise of my statement is that, as I know, there isno certain, complete and final epidemiological evidence
that circumcision prevents genital diseases, in such a waythat it should be universally recommanded bypediatricians.

189

people. Religious circumcision should remain out of
the medical sphere, unless a specific article in theprofessional code of ethics and an explicit state law
require physicians‟ help, for the sake of public order,
but
these
exceptions
must
remainfew,
democratically approved and transitory. We canallow a surgeon to heal the broken wing of an eagle,
if no veterinary is available. But it must be clear that
this is not a medical duty.
To avoid interferences between religions andmedicine, to prevent undue medicalization of cultural
traditions and to oppose dramatic collusions between
medical power and arbitrary individual desires,
medical ethics should defend its beneficent intention.
In the case of male circumcision, my proposal wasthat it is administered by imam, rabbis, generally
speaking by religious ministers, who will bear thelegal and moral responsibility of their performances.
Of course, it would be useful (and perhaps legallyrequired) that they attend preliminary lessons andmake a good training, under the supervision by
medical experts, to assure a satisfying level ofhygienic and sanitary safety (as it happens forpiercing offices). When the circumcision is performedin adult people and the intervention becomes quite
similar to an invasive surgical intervention, the only
solution I see is to require that the religious minister
is a medical doctor in every respect.
Let us take an other debated example. It is quite
easy and common to criticize the doping in sports
and to establish punitive rules for physicians foundguilty of complicity. It is less easy to offer ethicalreasons supporting such blame. If medicine extends
its domain by including any kind of invasive bodyreshaping, if no professional moral promise exists but
following the competent, free and informed desire ofa paying client, if the quality of life (interpreted as thearbitrary, boundless customers‟ desire of a better
existence, even in the absence of any diagnosed
physical disease o mental disorder) is the only
criteria to define the proportionality of a biomedical
treatment, then it is time to say farewell to codes of
ethics prohibiting the use of some performanceenhancing substances. The difference itself between
use and abuse would be fated to disappear. The
movie picture Any Given Sunday directed by Oliver
Stone (Usa 2000) is a faithful, upsetting portrait ofthis moral storm.
The economic market pressures, the managers‟
ambitions, the advertising allurements and the cruelcompetitive atmosphere, we all know, will create
dangerous slippery slopes. But dangerous for whom?
An athlete might evaluate as minimal or tolerable risk
a drug adverse effect, because he/she evaluatessome sport results as a primary end of his/her own
life and he/she would jugde paternalistic any refusalof cooperating with such a project. Even theobjection of unfairness has received coherent replies:
if all the sportsmen (in either agonistic, professional,
or amateur-practices) were allowed to get the drug
(and even gene-doping) they need or want, in atransparent and libertarian way, this technicalmanipulation wouldn‟t contradict the gentlemen

190

Eubios Journal of Asian and International Bioethics 20 (November 2010)agreement of loyalty and of an equal starting-point,that the contest requires. Who can and want to takea substance or to use a prosthesis, he/she would beallowed to do it: personal will is respected and thestarting point simply reset. Isn‟t sometimes thenatural lottery itself a more scandalous discrimination
among runners?
How could we solve the dilemma? Lists ofbanished products are based upon agreed rules ofconduct, and the rules upon ethical principles andtheories, but - last of all - ground narratives andvisions of a good life (of a fair sport, of a beneficent
medicine, of an healthy body) give the philosophicalframework, the convincing language and the leading
metaphor, by which individual and societies might
mould together an ideal and a treaty about what
represents a worthy and happy mutual respect andaid. We need parables, rooted in religious or secularenvironments, to draw an universal contract of giving
and receiving, in the world of sports, too.
Conclusions: what metaphors, what tales ofcare?
Sometimes the ethical heart of clinical enterpriseseems so confused, ambiguous and anaemic as thescared, chilly, tired body of a rash beast of prey,
which has lost its own way. In the three contexts wehave examined, it is clear that advanced medical
science and practice require a new ethics, which is
not based upon abstract, impersonal and generalprinciples, whose meaning may seem prima facie
univocal, but admits, in a hidden way, so manydifferent points of view, that the theoretical structure
and the intellectual coherence of the syllogistic moral
deduction collapse in front of the relevant dilemmas,
we have to face in our society. To make an effective
use of terms like “proportionate care”, “responsible
desire of child”, “properly medical scope”, “fair sport”,
we have to rediscover the stories of origin, themythical narrative, the visions of just society, where
theories, concepts and principles take roots.
An hermeneutical-narrative ethics, that recognizes
the symbolic dimension of our thinking, thegenerating metaphors of our language, and theaesthetic feature of our decision-making framework(also in the medical field), cannot be explained in this26
article .We have just the room to say that the goodaction (and also the good medical decision) is like awell-made work of art, that is, at the same time,
absolutely original (because it is created once andforever by an individual artist) and universal

26

See for example our book Bioetica e cinema. Raccontidi malattia e dilemmi morali, Milan, FrancoAngeli, 2006
(2nd Ed.) and our articles: “Application or Interpretation?
The Role of Clinical Bioethics Between Moral Principles
and Concrete Situations”, Analecta Husserliana, LXXII,
2001, pp. 99-115; ”Clinical Bioethics. Identity, Role, Aims”,
Medicina nei Secoli - Journal of History of Medicine, 13/1,
2001, pp. 187-197;”Moral Norms and Hermeneutics inClinical Bioethics”, Medicina nei Secoli - Journal of Historyof Medicine, 13/1, 2001, pp.199-209.

27(because it claims the approval of all the audience) .
In a similar way, a good action deserves to be madeunconditionally, for the reason that it honours themoral agent‟s desire both of happiness (the old
Greek people would have said “of eudaimonìa”) andof justice (by opening a world, where everyone might
be treated with equal compassionate care).
Advanced medicine needs these symbols ofsolidarity and the strength of an ethical vision (about
the beginning and the end of life, the meaning ofcare, the value of body, the scope of sportperformances), not to stumble in an embarrassing
humanistic stammer. Acting for the good of suffering
persons requires a rationally justified synthesis ofscientific knowledge, technical expertise, sense ofjustice, moral integrity and sensitive style ofrelationship. There has to be aesthetics in medical
ethics, because there is creativity, emotional
involvement and perception of elegance in medical
practice. A novel can help us again.
“Can’t you let a man die as comfortably as he canwithout calling him names? What’s the use ofslanging me?” “You’re not going to die.”Upon Kilimanjaro, close to one of its summit, there is
the dried and frozen carcass of a leopard. No one
has explained what the leopard was seeking at that
altitude.
When we rightly oppose the evil of death and of
malignant diseases, we make a promise, which isworthy, even if we have no guarantee to realize ourdesire. Something might go wrong and make us
loose the way, like that frozen leopard carcass. But
we must not give up the pleasure and the duty ofnarrating the stories and the worlds, that feed ourhope as caring individuals and institutions. This is
one side of the work of ethics.

Sex Selection in Asia, witha focus on Thailand- Napat Chaipraditkul
Research Assistant,
Eubios Ethics Institute, Bangkok, Thailand
Email: napat@eubios.info
1. Introduction
Humans are capable of many actions, and also
have moral responsibility for their choices andactions. One of the dominant ideas to all living beings
is “the continuation of species”, or simply
reproduction. What makes reproduction so
important? Reproduction helps to continue thespecies and through it inheritable physical andmental characteristics are passed from parents tochild. Among humans, there is segregation between
two sexes, males and females. In some countries,
infants especially females are rejected, avoided oreven not allowed to be born by their parents,
because of prejudice against girls and women. In this27

Estetica nell’etica. La forma di un’esistenza degna is thetitle of the book we are now preparing.

Eubios Journal of Asian and International Bioethics 20 (November 2010)
paper, I will examine the biological aspects of genderdifferences, methods of sex selection, and someassociated ethical and social issues.
2. Biological understandings of males andfemales, and reproduction
Reproduction of all living creatures is divided into
two main types - sexual and asexual. Humans use
sexual reproduction with males and females. The
28
human genome has 23 pairs of chromosomes , with
one pair, the sex chromosomes (X and Y), which
determine sexual features biologically, and 22 pairs
29
of autosomesthat do not determine sex. The
female has a pair of X chromosomes whereas themale has one X and one Y chromosomes.
The process of reproduction is that males produce
spermatozoa, which contain XY chromosomes
whereas female‟s produce ovum with XX sex
chromosomes. The fastest (and/or strongest) sperms
have more chance to fertilize the ovum than weakersperm. If there is a Y chromosome the embryo
formed will be male. The sperm will determine the30gender of the offspring, not the egg. In nature,humans cannot predict the gender of the unborn
child or fetus, until the time when the mother delivers
the child.
3. Sex determination of the embryoSome parents would not be satisfied if the child
who is born is not what they wanted or expected. In
the past, parents also couldn‟t take precautions
against the defects that the child might inherit fromthe parents. Nowadays, the world has changed andmedical technology has advanced. Biotechnology
has been used to provide benefit to society
throughout history, but there are also risks that it will
be misused. As our knowledge has grown about thestages of pregnancy, reproduction, sex determination
and abortion, couples can learn what to expect andcan try to avoid the unwanted. The couples who
cannot conceive their own children are considered
infertile, and some attempt to use assisted
reproductive technologies, such as in vitro
31
fertilization [IVF] . Although, IVF is very useful formany infertile couples, gestation is not always
successful and being costly could lead the couple to
be in a great debt. There is only a 20 percent
28

Chromosomes FAQ, Genomic.Energy.Gov, Genome
programs of the U.S. Department of Energy Office of
Science, Founder of the Human Genome project andleader in systems biology research, 12 September 2003
http://www.ornl.gov/sci/techresources/Human_Genome/pothsters/chromosome/faqs.shtml> Accessed 19 April 201029
Griffiths, Anthony J.F., Sex Chromosome and Sex-Linked
Inheritance,
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=iga&pa
th
rt=A222> Accessed 19 April 19, 2010
30
th
Cell
Reproduction,
4
Febuary2010
http://anthro.palomar.edu/biobasis/bio_2.htm
Accessedth
18 April 201031
What is in vitro fertilization [IVF] and how does it work?,
retrieved from http://www.hfea.gov.uk/IVF.html Accessed in20th April 2010

191

success rate for implanted embryos to be born as ababy each cycle (Engelen and Vendevelde, 2004).
Some married couples who are experiencing thedecline of age and infertility can be desperate tohave a child. Other couples may also have the ideaof perfection and how their child would be. IVF canbe considered as a standard alternative forreproduction for infertile couples. In fact, technology
has its way to make our lives easier, yet thetechnology does have some flaws as well. It leads to
new alternatives for human choice and while
conception of babies for infertile couples is possible it
could lead to discrimination if embryos are selected
due to their sex.
There are several alternatives for gender selection
for couples. First, preimplantation genetic diagnosis(PGD) is primarily developed for tracking genetic
disorders or defects, however it can be also used topractice sex selection. PGD helps to prevent
unwanted fetuses who are at risk of inheriting sexlinked hereditary abnormalities from the parents; forexample, congenital diseases, Down syndrome, andthalassemias. In the case of autism, some parents
may choose girls over boys because there is areported increased chance of autism in boys
(Savulescu, 1999). Consequently, PGD seems to bean appealing decision for the couples who do not feelthat they could raise a child with a serious handicap,
or else those who think it is painful for the children
with these diseases. Of course there are many
ethical debates over the ethics of PGD.
The screening of the DNA for physical anomalies
or genetic defects usually uses Fluorescence in situ
Hybridization (FISH) (Malpani and Modi, 2002). It canbe used as a screening device for defects that might
be inherited or pose a threat to the embryos.
However, apart from the reason that has been
mentioned, some couples wish to use PGD to selectthe gender of their infants. Due to the advances ofmodern technology the sex of the embryo can bedetected by a maternal blood sample within 6 weeks
of gestation whether, they are female or male
(Macer, 2009). Ultrasound can be used from 11 to 13
weeks of fetal growth (Macer, 2009).
The cell or tissue samples from fetuses can betaken through amniocentesis or chorionic villi
sampling, and then these samples can be screened
by FISH. Ultrasound is widely used, since it is noninvasive, and it allows us to visualise some physicaltraits of the fetus. Any of the regular methods forprenatal diagnosis can be used for sex selection.
Prior to conception, sperm selection can be used
before artificial insemination, where the sperm is
injected into the vagina. There are several
techniques which separate sperm, either based on
their density or swimming ability of those who carry
two X or XY (lighter) chromosomes (Parliamentary
Office of Science and Technology, July 2003).
There are even more simple methods from popularbeliefs that are said to assist as preconception
methods for fertilization of particular genders. Some
may agree to dieting to increase the possibility ofconceiving a particular sex, for example, bananas,

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

grapes, and beans are said to help conceiving maleembryo (Liao, 2005).
4. Physical Differences between Sexes
People are judged by their physical appearance
everywhere. The first aspect that people see ofothers is their physical features such as race, skincolour, height. Men and women are judged by their
physical structure as well.
It is a universal belief that men are physicallystronger than women, what make us different.
Basically except for the changes induced by the Y
chromosome, women and men are identical having
the same genetic structure. The 23rd pair ofchromosomes define the sex of an individual.
Besides genetics, the feature that separates gender
are hormones that controls male and female
behavior and emotions. Testosterone is the so-called
male hormone, and estrogen is the female hormone.
There are variations in the amounts between every
individual in a gradient. The hormones influencephysical characteristics, for example, comparing
male and female voices, the pitch of a women‟s voice
is higher than men due to higher levels of estrogen. It
controls voice production features which clearly
separate men from women. Not only do these
hormones control the brains of males and females
during early physical development and later on.
Many would say that men and women have different
ways of thinking that depend on their brains. A
person‟s behavior is affected by growth hormones,
sex hormones and stress, which are also related tothe brain‟s anatomy. "Males and females lookdifferent, we act different, so of course our brains aredifferent," said Tracey Shor, a Rutger University
32
psychologist.
The sex hormones dominate sexual behavior fromthe age of puberty. The sexual identity of the brain isdetermined by hormones. In research on animals, anexperiment to extract testosterone out of the maleanimals had the result that the male tend to behave
like females despite of their gender. The physicalcharacteristics of males and females are influenced
by testosterone and estrogen, respectively. It is
generally believed that the sex hormones don‟t takeaction until the age of puberty, which is when aperson‟s body will be ready for reproduction.
Estrogen and testosterone are both produced in the
hypothalamus.
33
A neurobiologist, Larry Cahill,
conducted anexperiment in which the subjects were men andwomen who watched the same emotional film. It theresult shows that men were more stimulated on theright side of the amygdala, while women were
emotionally aroused by the left side (The amygdala isa brain organ in the limbic system which controls
emotion and reactions). The right and the left handsides don‟t work the same in both sexes, the left sideof the amygdala is stimulated by the outerenvironment and visual stimuli, and connected with32

the visual cortex. The left side focuses on the inner
atmosphere of the body producing emotion bysenses and experiences. There are some sex-linked
tendencies, for example, males are more prone toalcohol and substance abuse, but women are more
prone to their depressive and unpredicted emotion.
However, we should not stereotype traits to gender.
5. Social construction of gender
Gender and Social Roles
Most societies divide humans into two maingroups by their sexual appearances. Society also
determines the genders roles. In every society there
are rules that manage everything. There are roles fordifferent people and roles are given such as
occupation, titles, and family members. Humans also
create that role for each individual, men and women.
Throughout history humans have been taking thesame path of aggression, war and strife. Men andwomen have been the victims in the times of conflict,and also in domestic affairs.
The simplest way to categorize males and females
is their physical features and behavior. Men are
known as being independent, strong, reasonable,
smart, yet aggressive, but women are assumed to be
dependent, weak, gentle, and passive. Males andfemales are even stereotyped by their choice of toys
during their childhood. Boys play with robots and girls
play with dolls. While boys are encouraged toexpress thoughts and given more freedom, whengirls grow up, often they are expected to be
responsible for traditional practices. Girls are usually
responsible for preserving cultural values andburdens instead of showing their individuality. Males
and females have different responsibilities in
response to social demands. For example, intradition, men go to war and fight for their nation,
while women look after their husband and children.
We could assume that each is responsible for certain
duties but why do we keep on encourage competition
among males and females, instead of supporting
compassion and admiration, and welcoming newchanges of social roles among both sexes?
Obviously, males and females are responsible fordifferent tasks, but in many cultures males are
considered superior to female. Women have always
been portrayed as an object in the family. For
instance, there is a saying that "There are three nonfilial acts: the greatest of these is the failure to34
produce sons." (Confucius). Women are simply atool for reproducing male infants to serve male–oriented social expectations. Eventually women are
obliged to have a son to achieve a better family
hierarchy and societal status, whereas those who
don‟t produce a son face ignorance anddiscrimination. Women themselves also struggle fora better status in the family. In the same way, theChinese prefer a boy over a girl because of theirmale supremacy beliefs which have continued in
Chinese families for many centuries. A son means
the survival of the family line, whereas daughters areth

Kotulak Ronald, Tribune science reporter, 30 April
2006,Accessed 20th May 2010
33th
Kotulak Ronald, Tribune science reporter, 30 April
2006,Accessed 20th May 201034

Retrieved
http://www.womeninworldhistory.com/lesson3.html

fromEubios Journal of Asian and International Bioethics 20 (November 2010)
married out and have male children. The borrowingof Chinese characters in Korea, for example, affected
Confucius male preference, when it was first spread
and adopted at the beginning up to the middle reignof the Choson dynasty which still exists in Koreansociety and culture until now. The strong kinship is
linked to male preference, where the roles of family
members are fixed traditions of authority kinship(Chung and Das Gupta, 2007). Men and women
through the centuries have been given roles as a partof a patrilineal social structure. Consequently, thestrong preference for males by people was followed
and implicitly agreed upon, with corresponding
assignment of roles. This is maintained perpetually.
To conclude, we can see three general reasons formale child preference. First, the symbolic significant
of continuing the family line. Second, they inherit
power status from adults. Third, sons were financiallyempowered by being responsible for their parents,
whereas daughters do not hold much power orauthority in their household (Bélanger, 2002). All inall, since the domestic role of women in a family is
disvalued and not appreciated, therefore, they are
dependent. Many years of constant stereotyping maylead to serious practices against women. From theseideas the perspective of desiring sex determination ismore understandable.
Gender-based stereotyping
Stereotyping is a generalization of some aspectsof certain issues. The perception of gender isdetermined by socio-cultural norms. There are rules
for social conduct for each gender which are
intrinsically practiced by people in each society andculture, and among specific groups. I would like tofocus on gender stereotypes, which are reinforced in
our mind as soon as we are born.
Men are expected to be strongly independent andunemotional. They are encouraged to be involved in
sports and competition. Men are generalized as aleader and risk taker. However, in one study, where
the subjects were male patients with cancer for one
to five years, it was shown that had experienced
nervousness and anxiety. They were allowed tochoose a place of their own. Men were told to abstain
from the liberty of personal expression, many of themhad never sought assistance and a few of them
privately cuddled stuffed toys, wept in their cars, oreven took time away from their family in order toseek their own comfort. They followed the concept of“self control” which is expected of men (Moynihan,
1998). Men are forbidden to show their frustrationand fear. Men are highly regarded because they
withstand the pressure by their high social standing
in a so called patriarchal society, which ironicallyforces them to suffocate their own freedom, and eventhough at times men are weak, and need an
opportunity to show grief as a right of expression andcomfort. Compared to women, they have moreadvantages for seeking shelter, being protected,
giving and getting emotional support from both sexes
while men are hiding and suppress their grief.

193

What are stereotypes of women and the prejudiceagainst
them?
Women
are
emotional,
compassionate, sensitive and gullible. The ability ofunderstanding mathematics of women is considered
inferior compared to men by some psychologists andbiologist (Fausto-Sterling, 1985), due to the difficultyof having menstruation and having a different brain
structure to men. Normally, most women haveexperienced menstruation which is linked to their
biological roles for ensuring future generations. Thisillustrates that women may be discriminated in theirwhole being, in a sense judged as “guilty” from theirage of puberty. However, men also are biologicallydesigned for reproduction, and have particular issues
from puberty onwards such as production of sperm,in the same way. Stereotyping gender roles will nothave positive consequences to end misogyny. New
techniques of sex selection using assisted
reproduction have led to further serious gender
discrimination.
6. Traditional practices against women’s rights
and freedom
India has a practice called the rite of Sati
(Machacek and Wilcox, 2008). The sati rites originate
from the story of a chaste lady called Sati, whocremated herself for her husband Siva, because she
could not stand her father‟s humiliation of her
husband. The rite itself is known as a ceremony inwhich a wife is willing to die by being burnt on thefuneral pyre to follow her dead husband after his
death. If a wife complies to the ceremony she will beconsidered as a goddess; therefore, the death ofwilling or unwilling wives causes the expectations of
women which is at the same time against humanrights and sovereignty. The rite of Sati lessens thewomen‟ worth in Hindu society. For example, in the35
epic of Ramayana, Meghanatha‟s wife, Sulochana ,cremated herself to death in honoring her deadhusband.
These traditions all contribute to the social
preferences of the gender of infants? A woman who
delivers a female infant is considerably wronged or
mistreated by not giving birth to a boy due to thefinancial burden that would be coming later on
because the parents of a woman have to have pay adowry to the groom‟s parents. These cultural
practices illustrate how the child being born as a girlhas to experience many challenges. With this line ofthinking, some Indian people don‟t want to have ababy girl. Women will be a burden on the family.
Once they get married, the dowry is paid to thegroom‟s family. There are also some cases of brideburning as a consequence of low dowry payment.
The family of the bride must pay the dowry for thegroom‟s family, and if the payment is not as high as
they wanted, the bride may feel that she shouldcommit sati practice. The social system has worked
its way to develop a great deal of discrimination
35

Indian epic values: Rāmāyaṇa and its impact:
Proceedings of the 8th International Rāmāyaạ Conference,
Leuven, 6-8 July 1991, Gilber Pollet, Peeterspublisher,
pg.63, retrieved on 11 August 2010.

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

against women, and also to high levels of physicallyabuse and even death to women. The repeatedscenarios of abuse against women can be seen in
many societies.
36
Hofstede has categorized what people value ingroups in their society around 50 countries, anddivided between collectivism and individualism. A
collectivist society focuses on the entire society, isfamilyoriented,community-based,promotesinterpersonal harmony, and avoids conflict. While thesecond type, individualistic societies tend to value
self-respect, freedom of speech, be liberal, promoting
self-fulfillment, individual needs and satisfaction.
Collectivist culture is seen in countries such as India
and China, mentioned above. They are ones where
people agree on consensus, whether people in thesociety are valued on any matter.
One of the famous Chinese philosophers,
Confucius said that "disorder is not sent down by
Heaven, it is produced by women." We can see thiswhen an infant is born with defects or deformities, themother is the first one to blame. This attitude not only
affects the discrimination of female fetus but thefemale in general as well. Where does this idea
come from? Is it appropriate to put the blame on
patriarchal collectivistic societies?
India also highly values men similar to China andThailand as collectivistic cultures. Due to the fact thatIndia is also a collectivistic society this practice iscommonly practiced among many Indians. This
practice devalues females in the society thus
contributing to female infanticide. In one study of agroup of 450 women in India who went to an urban
clinic, 430 women aborted their female babies(Malpani,2002).
Anotherpaper
examined
preferences for boys in Northern Vietnam. In families
of four persons or more, the families try to reduce
their girl members, and continuously, having boys,
they are affected by having small land ownershipwhich causes poverty. Married women without sonsare blamed by the family that they do not have sons
(Bélanger, 2002).
Imagine if more than half the women in a country
have experienced sex selective abortion. The sex
ratio would obviously become imbalanced and thiswould be followed by a drastic change in the society.
What type of changes would this make in society?
Nathan Keifitz, a demographer claimed that sex
selection abortion may change gender inequality
because it reduces the proportion of women, andtherefore this could even make the remaining womenpotentially more powerful (Bélanger, 2002). On theother hand, there is an estimate that if there are too
many males, the rate of prostitution will be increased.
The scarcity of women may make it even moreharder to find mates leading to polygamous
marriage, in addition to higher rape rate, abduction
and incest (Macklin, 2009). There could also be
increased homosexuality. The ratio of males tofemales is very important to maintain, as we canimagine what could happen in the future if the ratio of
36

Larry D. Samovar, Richard E. Portor, Edwin R.
th
McDaniel, Communication between cultures. 6 edition,Thomson Wadworth.

both sexes is greatly imbalanced? The ratio of males
and females in the population should be equal. If
women are the majority, the male would not find adifficulty in finding their mates; on the other hand,some women could not find a mate. We shouldn‟tignore the social consequences of imbalanced sex
ratio in the population.
7. Parental rights and limitations on genderselection“Why can‟t we get what we want?”, this classicalquestion leads to a further discussion on rights andlimitations . This question has been asked by many
people in every class and society. In the case of sex
selection, why cannot we decide the sex of our baby,
and who would be troubled by our decision? On theother hand, why we attempt to design our daughtersand sons lives? There are no parental rights to end
sons or daughters‟ life. This should be a clear limit onparental rights. We still, however, have to consider
what can be rights and limitations of parents.
Basically, parents hold the rights of parenthood
which decide a number of things for their offspring.
There are many possible ways of making a decisionin parenting which are conveyed by cultural norms
and social contract, in a form of sex preference. For
instance, India is economically and socially
supportive of boys, while girls are the victim of themainstream culture and so on. The notion ofautonomy of parental gender based selection seems
to be choice of the couples. As many studies
mentioned, the mothers appear to choose sex
selective abortion by their choice, however, in a
deeper aspect the choices made were strongly
influenced by their mates, parents and in-laws in
response to the threats of physical abuse, for women
to deliver male infants (Oomman and Ganatra 2002).
The decisions to abort or kill their own sons ordaughter is not an easy one to make, and thepractice was somehow associated with the low
income of families, economics, and the failure ofcontraception and family planning. We can see thecultural influences and societal pressure. The smallerscale of society is looking at each household andwithin each household consists of persons withspecific roles. The roles of family members can also
be influential in decisions to abort or not to abort thechild. Nonetheless, abortion after sex selection is nota decision made solely by the family but includes thewider socio-environmental surroundings.
8. Religious laws or doctrines
Some religious scriptures and customs include
discrimination against females. For instance,
according to Manusmriti of Indian Hinduism, [or as
known as the laws or ordinances of Manu], apartfrom the caste system, it is also included the femalebiased ideas which mentions Hindu women are
restricted to live their lives and survive, namely, "In
her childhood, a girl should be under the will of her
father. In her youth, of her husband. Her husband

Eubios Journal of Asian and International Bioethics 20 (November 2010)
being dead, of her sons. A woman should never37
enjoy her own will.” [Laws of Manu c. 200 B.C.]
In the Christian Bible and Jewish Torah, itmentions that the women will be unclean after
delivering a boy for one week, but if she delivers agirl, she will be unclean for two weeks. Thisillustrates a form of gender discrimination towards
38
female babies (Leviticus 12: 2-5).
Christianity
regarded women as neither pious nor evil. However,
the exaggerated image of being virtuous or
despicable distorts the image of women in reality,
who are simply human. For instance, in medieval
Europe, where Christianity spread, idealistic pious
women were compared to the Virgin Mary, whilesome other women who were perceived by intolerant
judgment were considered as witches, temptress or
39Eve, the culprit for the original sin. In the Bible, atthe beginning of humanity, God in Heaven creates
man in the same image of himself, then God creates
woman out of Adam‟s ribs. Eve was easily lured by
the serpent to take forbidden fruit. Eve lose her faithin God, and decided to trust the serpent instead. As aresult humankind is banished from the Garden of
Eden. Accordingly, in this tradition women are
untrustable, maleficent, and greedy. Women areblamed for such act. This belief has been taught
through generations in western world. The image ofMary is a perfect female model. Thus the expectationof women in a male dominant perspective will meanthat there is less freedom. This makes the status of
women inferior to men, while men are in the sameimage of God himself. In most religious traditions
around the world the Earth is associated with mother,and God with a father. This suggests intrinsic female
discrimination.
All in all, the devaluing of females is the cause of
female feticide and infanticide. The level of women‟svirtue was lifted so high that women have lost theirrights to live their own lives, and to be themselves
under the high societal norms. Therefore, women areoften treated immorally. According to religious laws,
those who don‟t comply with the law will be punishedby detested people in society empowered by gods orreligious ordinance.
9. Infant Fertility and Mortality Rates
From the infant mortality rate calculated for
different ages of children we may find signs relating
to severe neglect or abuse of children. The infantmortality rate in Thailand compared to India for 2009is in Table 1.

40 41

Table 1: Comparisons of India and Thailand ,Thailand
India
Infant mortality rate:
Infant mortality rate:
total: 17.48 deaths/1,000 total: 50.78 deaths/1,000
live births
live births
country comparison tocountry comparison to
the world: 114
the world: 51
Male: 18.48 deaths/1,000 Male: 49.33 deaths/1,000
live births
live births
Female: 16.43
Female: 52.4
deaths/1,000 live births
deaths/1,000 live births(2009 est.)(2009 est.)
The rates show significant differences between
Thailand and India, but the Thai population is muchsmaller than India. One comparison shows that themortality rate of female infants in India is greater thanmales, but in Thailand males have a higher rate thanfemales. The ranking doesn‟t indicate the cause of
the mortality of infants. India is infamous for its malelinear dominated society and there has been aproblem with the sex ratio demographics of the maleand female birth rate because of sex selective
abortion. In the case of India, in Maharashta,
according to a report, the figure shows that from agroup of 1,409 women who had an abortion in
Maharashta in India, all 253 women who wereinterviewed said that they had an abortion because
they don‟t want to have girls, i.e. they wanted to abort42
the female fetuses.
If we compare the number of infant‟s born inThailand in 2007, there were 417,783 males for393,601 females, meaning an excess of 24,182 extra
43
males.
When we consider the mortality rates of
infants in the world, the highest rate of infantmortality in the world is Angola, with 180.21(deaths/1,000 live births) in 2009. India held 51st
place in the ranking of infant mortality (50.78) whilethThailand held 114 place with (17.48).
10. Interview Research among the Thai public
The parents themselves are one of the main
reasons for gender determination, and in the case ofThailand, I conducted interview research to ask somequestions regarding gender preferences with 65
people from June-July 2010. The average age of
respondents was 30 years, ranging from 20 to 49
years of age. Within the respondents there were both
Chinese-Thai and indigenous Thai.

40

37

Laws
of
Manu,
retrievedfrom
http://www.duhaime.org/LawMuseum/LawArticle-297/200BC--Laws-of-Manu.aspx,retrieved on 16 June 2010.
38
Leviticus 12:2-5, the Holy Bible, New International
Version, 1988 printing
International Bible Society.
Retrieved on 18 June 2010.
39
Josie P Campbell, Popular culture in the Middle Ages,
Popular Press, page 48-49. Accessed in 27 September
,2010

195

TheCentralIntelligence Agency, TheWorldFactbook, 22
April 2010 https://www.cia.gov/library/publications/theworld-factbook/geos/th.html Accessed 26th April 2010.
41
The Central Intelligence Agency, TheWorldFactbook, 21
April 2010 https://www.cia.gov/library/publications/theworld-factbook/geos/in.html Accessed 26th April 2010.
42
Bela Ganatra, Siddhi Hirve, V. N. Rao, Sex-Selective
Abortion: Evidence from a Community-based Study inthWestern India, page 4, accessed 6 May 2010.
43
Department of Provincial Administration of Thailand,
retrieved from http://dopa.go.th /xstat/tran/birth50_1.html
thaccessed 9 June, 2010.

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Eubios Journal of Asian and International Bioethics 20 (November 2010)

Of the 65, 35 persons said they preferred boys, 18
persons said they preferred girls, and 12 persons
said they had no preference. They gave a variety ofreasons for their gender preference for babies, as
open comments written on the questionnaire. These
include:• Boys are easy to raise as they do not need too
much attention and caring.
• Baby girls are more adorable than baby boys
• Boys are cute
• There is no point having girls, nowadays thecost of living is so high, boys are the better choice• When a woman got married, she can no longer
use her family last name, and therefore she will facedisadvantages in her working life. It is hard for amarried woman to pursue her career.
• It‟s better to have a boy from the beginningsince woman cannot continue the family name.
• Girls, when grown up can take care of theirfamily, but boys will take care of their wives andchildren, they will no longer support their parents.
• Boys don‟t talk too much, they are not whiney.
They are the leader.
• Boys or girls, it really doesn‟t matter, they havedifferences and similarities; good or bad such as theyare. No one can say which is the best.
11. Interviews with medical professionals
I conducted interviews with health professionals in
Bangkok about sex selection. Let me begin withquotes from threes doctors‟ interviews regarding
gender selection.
“There is an alternative for the couple who could
not accept the sex of the fertilized embryo in case ofa particular unwanted gender. Secretly, they would
try to ask the doctor for a new appointment for new
fertilization and have the new fertilized embryo.”
Telephone interview [anonymous 1]
The doctor however did not explain what actually
happens to those unwanted embryos. Is the fertilized
embryo considered as a human being although they
are not human-like at that stage? Do they have rights
to be born, this will always a question that has
different answers.
“I do not believe that Thailand has a strong genderpreference on boys or girls, we don’t have that kindof tension to pick the gender of the baby. Although,we have Chinese-Thai families in this country. For
example, in China the one child policy made adramatic imbalance gender ratio where boys
outnumber girls. The root of gender selection ismainly in China, not Thailand.” Telephone interview[anonymous 2]
He does not believe that sex selection andpreference has played a part in Thailand and strongly
mentioned China and the one child policy.
A third doctor said:“Sadly, most parents that came to this hospital
prefer boys to girl. The parents preferred to havebaby girls rather than boys, because they once had avery talented woman in their family. She was very
successful in her career. So, in this case girls are
more preferable than boys.”

The doctor did give an interesting point of whysome parents prefer boys to girls, if they have atalented female in their family in response to thesocial and economical status of a woman; therefore,
she will be valued by such attributes and qualities.
In this certain aspects female infant are moredesirable and needed (Sen, 1992). The doctor evenclaimed a case that girls are more preferable if she isexpected to be talented. Otherwise she would be
neglected by her parents. The case of Thailand stillneeds to be investigated. The three interviews, andthe comments from the public suggest a preference
for boys in Thailand, greater than that for girls.
12. Discussion
We have examined biological, physical and social
aspects that are linked to gender discrimination
which may lead to sex selection abortion. In
conclusion, biological factors do not cause gender
based selection. Biologically, human reproduction
has its own way of determining the gender by thestandards of perfection that work in nature, without
human notions of perfection or preference. Although,sex chromosomes, X and Y, ensure the continuationof the human species, the differences don‟t lessen or
increase the value of being a female or male humanbeing. Babies are born to continue humankind;
therefore, there is no discrimination or segregation
against sexes. When a human is born he or she willusually differentiate into a particular gender, and be
44
stated as a particular gender.
Consequently
persons are categorized by social roles.
Most males and females are capable ofreproducing their future generations. South East
Asian women are trying to overcome sexualinequality and degradation of women, and the factthat men and women are treated by different
standards. Men and women are supposed to betreated with arbitrary standards of masculinity andfemininity, which can be accepted and agreed on by
their preference, and which are also sometimes
protected by legal instruments. Female feticide andinfanticide should be stopped if the specialists are
not willing to comply with the parental choices ofgender, except for medical reasons. Medical doctors
should not comply with the parents‟ desires. Ironicallythey often provide the alternatives for their patients toabort female fetuses. Parents should give
unconditional love towards their children whether
they have a boy or girl. Doctors should be ethical in
making a certain decision as well as parents. We
cannot simply judge who is responsible for all ofthese abortions, the medical specialist or the parents,
but we should consider that we are humans and whatmakes the fetus, at least a person-to-be, deserve
lesser kinds of protection. Do embryos have the rightto live on as persons with legal rights and humandignity, even though the parents may have chosen
44This paper does not consider transgender persons, andthose who seek sex change operations. It is the topic for afurther paper to examine sex selection and transgenderissues, and many arguments that apply to the preferences
for females or males, would also apply to transgender
identities.

Eubios Journal of Asian and International Bioethics 20 (November 2010)
for them to be disposed of because they are female?
Who can be an arbiter of deciding which sex is morevaluable, and thus which person is more valuable,
and who deserves to be able to be born or to live inthis world?
There has been a lot of discussion in the literature
about the possible reasons for female fetal
discrimination or infanticide. Socially, females areburdened with domestic affairs, which disable womenfrom expressing as much autonomously fulfilling theirown needs and satisfaction. Women are bound tocultural norms and practices, which they need tocling on to for social survival. If not they are
considered as an outcast. This is universallyacknowledged.
Some people even say that girls are not needed
unless there are some reasons behind conceiving ababy girl. Should a specific reason be given forpeople who are born or are they supposed to serve acertain purpose, if not should they be eliminated? Is it
ethical to kill innocent babies because of their being?
Religiously, women are either defined as objects
to be possessed, portrayed as either pious or
despicable beings. Women may not necessarily berecognized as an inferior gender. In some religions
there are bipolar images of women, from piety to evil,
which has created stereotypes of women.
Stereotyping leads to discrimination and prejudice.
More importantly, the concept of a perfect woman toa number of men should be one who is submissive
and even willing to sacrifice all of her being for her
given role. This often also includes abstaining fromfreedom of expression and liberation after centuries
of forcing women to be submissive. Determining how
women should serve society, women in many
cultures have been cornered into roles of those who
cannot defend themselves. On the other hand, men
have been put into position of leadership which we
can readily see in business and political communities
today, men are expected to take the lead yet they arealso told they should abstain from the sense of loveand belonging as a generalization of being
masculine.
The portrayal of gender discrimination is found inmany forms. A good example is the social struggle ofwomen as day-by-day survival. In this modern world,
there are many forms of female discrimination inexistence, and women perceive society pressure
through culture, mainstream beliefs, or daily media.
Women must follow the path that society gives. One
common classical trait used for discrimination isperceptions of beauty. Beauty is also considered to
be one of the factors that discriminate women. Many
women try to make themselves attractive according
to stereotypic forms. Perceptions from everyday
media are that beautiful persons are welcomed andadored. Women also often do cosmetic surgery, forexample, rhinoplastic surgery, or liposuction. Beauty,
perfection and expectations made us forgot
compassion and sympathy. On the contrary, if
humans rigidly differentiate themselves by genderdifferences, there would be no peace and harmony
since we are all individuals with distinct essentialities.

197

There are many broader questions, such as why do
we have prejudice against others, why women are
exploited and why do we tolerate the loss of freedomof others? Does it really matter what makes us a realhuman, male or female?
Protection of gender equality and humanity has along way to go. Where people are judging others byraces, skin colour, and sexes. Male and female
infants cannot be valued as equal, they are different
in many ways yet they are the same. The identicalfeature is that they are humans who need simply
love, nurturing, a sense of belonging, and chances.
Patriarchal oriented society might be a possible
causal effect on female discrimination yet it isn‟t; on
the other hand, the notion of being physically strong
made men receive less nurture and caring forexample reasons such as because they are boys,
they can take care of themselves. In conclusion, thetrue reason that causes female infanticide is hatredand prejudice against an alienated group - women.
Misogyny and hatred might be possible threatsagainst females, not solely the patriarchal society as
we understand. We cannot change things whichhave happened, but we can change society byteaching the value of lives to children at all ages,
supporting the promotion of inner-value andembracing people from all genders, classes andevery corner of society and eliminating ignorance.
13. References
Bélanger, D. (2002) “Sex Selective Abortion: Short-termand Long term Perspectives.” Roundtable / Reproductive
Health Matters 10 (19): 194-196.
Chung, W. & Das Gupta, M. (2007) Why is Son Preference
Declining in South Korea. The role of development andpublic policy, and the implications for China and India.
Policy Research Working Paper. The World Bank
Development Research Group Human Development andPublic Service Team October 2007 pp. 1-30
Engelen, B. & Vandevelde, A (2004) “Commentary: A
Defence of Common sense. A reply to David Heyd‟s “Theethics of sex selection for non medical reasons”‟”,
Ethische Perspectieven 11 (1): 84-87.
Liao, Matthew S. (2005). “The Ethics of Using Genetic
Engineering for Sex Selection”, J Med Ethics 31: 116118.
Macer, D. (2009) “Efforts to overcome sex selection in
reproduction in Asia”, J. International Biotechnology Law
6: 44-55.
Machacek, Wayne D. (2003) “The place of women in
Hinduism”, pp.110-113 in Wilcox, Melissa M., eds.,
Sexuality and the world's religions, ABC-CLIO.
Macklin, R. (1995) “The Ethics of Sex Selection” Indian J.
Medical Ethics Oct-Dec 3 (4).
Malpani, A (2002) “Why Shouldn‟t Couples be Free toChoose the Sex of Their Baby” Reproductive HealthMatters 10 (19): 192-193.
Malpani, A & Modi, D (2002) “Pre-implantation Sex
Selection for Family Balancing in India” European societyof Human Reproduction and Embryology 17(1): 11-13.
Moynihan, C (1998) “Theories of Masculinity” BMJ 317:
1072-1074.
Oomma, N & R. Ganatra, B (2002). “Sex Selection: The
Systemic Elimination of Girls” Reproductive HealthMatters 10 (19): 184-188.

198

Eubios Journal of Asian and International Bioethics 20 (November 2010)

Parliamentary Office of Science and Technology, U.K.
(2003) “Sex Selection” Postnote July 2003 Number 198
pp. 1-4.
Savulescu, J (1999) “Sex Selection: The Case For” pp.
145-149 in Kuhse, H & Singer, P. eds. Bioethics An
Anthology second edtion, Oxford: Blackwell Publishing.
Sen, A. (1992) “Missing Women” BMJ 304: 586-7.

Thai perspectives onabortion- Anniken Celina Grinvoll
Managing Director, Eubios Ethics Institute, Thailand
Email: anniken@eubios.info
Introduction
Abortion in Thailand is formally illegal except for
the reasons of rape, damage of the fetus or mental
health grounds. Despite restrictive abortion laws, anestimated two to three hundred thousands abortions
take place in Thailand every year. A significant
number of these are performed in illegal clinics whichhave no legally enforced standards, and often byuntrained practitioners. The illegality forces prices tobe high, treatment to be rushed, as well as stressful
and of poor quality. The necessary follow up of thepatient after the abortion to make sure the abortion iscomplete a week or two after may fall through with
the illegal clinics. This is the first ethical issue, thatmany abortions are performed with unsafe methods,
and continues to be an issue requiring policy review.
As a result of this, many pregnant mothers
experience injury, infections, infertility and evenmaternal death. The current abortion law in Thailand
has been the focus of public and political debate a
few times in the last decades, however those
opposed to liberalization of the law have managed
every time to let it remain as it is. What are thereasons for this and what is the view on abortion in
Thai society?
The issue of abortion remains crucial in terms ofThai women‟s health and women‟s rights. It also
demonstrates how women‟s bodies are used torepresent and affirm the nation‟s cultural values. The
government thinks liberalized abortion is a threat toThai culture and the gendered narratives it creates
about the nation.
Facts of abortions
Studies of abortion rates in Thailand are scarce as
most women do not admit to having had induced
abortions due to the illegality and social sanctions of
having abortions. A major hospital study was carriedout by The Ministry of Public Health in Thailand in
1999. This study was carried out among 787 public
hospitals, while the private hospitals declined being apart of the study due to the illegality of abortions(Warakamin et al., 2004). Socio-economic reasons
were reported in 60.2 % of the induced abortion
cases, while the rest were medically related such as
fetal anomalies (15.4%), intrauterine death (13.5%),
health reasons (7.8%), HIV infection (2.2%), rubella(0.3%) and rape (0.6%). Half of the induced

abortions were performed on young women under
the age of 25. The study also showed that as muchas 46.8 % of the abortions carried out by hospital
personnel complied with the abortion law regulations.
A study of abortions carried out outside hospitals
shows that one-third of the abortion cases, women
had serious complications due to having undergone
abortions performed by non-health personnel. A
contributing factor to an increase in the number ofillegal abortions is the country‟s national
development plans to reduce population growth andrapid modernization (Lerdmaleewong, 1998).
Thai society’s view on abortion
Thailand is a country where Buddhist thought ishighly influential and where 96 per cent of the
population claim to be practicing Buddhists.
According to Buddhist belief, to abort is seen as asin, as it is killing of lives. It is such a sin that leads toserious karmic consequences or demerit for themother, the fetus and even for those involved in theact of abort. The beginning of a human life, according
to Buddhist belief begins at the moment ofconception. Thus it is also argued that the later thestages in the development of the fetus that theabortion takes place, the stronger the negative
karmic consequences to the mother. Therefore, toabort at an early stage in pregnancy is mostcommon, followed by merit making afterwards(Lerdmaleewong, 1998).
Motherhood and reproduction remain a primarysource of female power and prestige in Thai society.
By giving birth a woman demonstrates her merit andas well as she improves her merit by providing theopportunity for the reincarnation of a life principle.
Abortion thus interferes with the karmic cycle andbirths and deaths by not allowing the rebirth of abeing. In so, Buddhism teaches that a woman will
inevitably suffer karmic retribution for her actions.
The women who reject pregnancy are also seen asof being not a real‟ woman and are depicted as aselfish being (Whittaker, 2004).
Also it is deeply rooted in Thai culture that abortionis felt as a national “loss of face” which is a verystrong notion of Thai culture which cannot beignored. Abortion is therefore seen as un-Buddhist,anti-religious and therefore also un-Thai. In fact theissue is a critical point to the national identity of thenation. The political opposition led by Chamlong
Srimuang against amending the abortion law was in
the 1980s quoted in saying that “we need to avoid
abortion in order to uphold and maintain Thai-ness”.
45

A female pharmacist (45) at a Bangkok based
pharmacy had this to say about the abortion pill:“This pill is dangerous and I don’t think you should
try to buy it either. I have experience with this pill, as
I used it for abortion myself. I will tell you about it. I
had to cut off my uterus because of the bleedings thepill caused. It is the worst thing that has ever
happened to me and my life. If you are considering
45

Matichon (Thai newspaper) (2 April 1988) “Chamlong
joins with four religious leaders for the second wave ofabortion law opposition”.

Eubios Journal of Asian and International Bioethics 20 (November 2010)
having an abortion I think you should stop thinking
about it. We Thai’s are Buddhists and it’s sinful toabort babies. It’s killing lives. It gives bad karma thatwill follow you everywhere you go. You won’t
succeed in anything, not in work, marriage or
nothing. It will also ruin your health. I tell you, you
should not do it. I do not recommend it. It is better tokeep the baby.”
Who are these women who have abortions?
In the media, during the times when focus wasstrong on the abortion issue the females who
underwent abortions were often portrayed as „loose‟,
immoral, party and fun seeking girls. Abortion was
portrayed as an immoral act by immoral people withimmoral lifestyles. TV programmes and media
coverage of the abortion issue tended to show
western images as abortion was associated with
Westernvalues.
Parliament
representative
Chamlong Srimuang who was strongly on the
opposition side to the reform claimed abortion wasan evil influenced by the West, which was not fit forThai society. He blamed the call for reform on
Thailand becoming more globalized and westernized.
Chamlong further suggested that rather thanliberalise the law Thai people should focus on the46
five pillars of Buddhism.
About the women who aborted not much werementioned about the problems of the other groups
including school girls, women with financial
problems,
deserted
wives,
those
whose
contraception failed, and married women. However,studies about abortion have showed that 75 per centof the women who seek abortion are married andprimarily motivated by economic or family reasons aswell as contraceptive failure (Koetsawang, 1993).
Another study that was undertaken by the Thai
Health Department in 2001 reported that 25 per centof the abortionists were students.
Thai law prohibits young girls who are still students(at any level) to become pregnant. Therefore, apersistent social problem is that pregnant young girls
desperately seek abortion to retain their student
status, otherwise they will be ordered to leave theireducational institution. A 19 year old student who
underwent an abortion for those reasons was caught
under a police raid on Pattanawet Hospital inth
Bangkok on 26 May 1994. Together with doctors
and other patients she was sentenced for the crimeof having had an abortion. The student however wassentenced the longest, two years compared to theelder women who aborted for other reasons who
were sentenced for a few months, according to47
national newspapers at the time.
Attempted reforms of the current abortion law
The peak times of the abortion debate in Thailand
took place in the 1980‟s and 1990‟s when the issuesof reforming the abortion law as of 1957 was brought
46

Matichon, (14 April 1988) “All religions must strengthen
to oppose free abortion law”
47
The Nation (English language newspaper) (4 Sept.
2001) “Police charge abortion girl”

19948

to public awareness. Many publications can befound that are pro-reform published detailing legal
and medical arguments about the adverse social
consequences of the restrictive law, as well as thesocial problems and the lack of women‟s rights todecide over their own bodies. A group of proreformers such as physicians, lawyers and womenactivists came with one proposal, that pregnant
women should have more rights than the fetus before
12 weeks of pregnancy and that the fetus shouldhave more rights after 12 weeks. This however, did
not have any success (Warakamin et al. 2004).
Again, in 2001 the issue of abortion was broughtup for discussion but was soon ended when the story
known as “Hell clinic” reached the front pages of thenational media. An 18 year old school girl had goneto a Bangkok clinic to have an abortion in her 8thmonth of pregnancy. Despite the late stage ofpregnancy the untrained doctor agreed to performthe abortion for a large amount of money, which
ended in a tragic case where the Doctor had to cut
off the baby‟s arm due to complications. Further
complications followed and the girl had to betransported to a hospital, which immediately gave her
49
a cesarean section.
In the aftermath of this the
Public Health Minister Sudarat suggested that to“focus on ethics and correct behavior in adolescentsis better than changing the law”. The issue ofabortion was again closed and a following up andcrack down on illegal abortion clinics throughout the50
country with penalties followed (Bamber, S. 1997).
Results of interviews
Wanting to find out more on the accessibility of
having an abortion in Thailand I conducted aninterview with Dr. Kamthorn from Chulalongkorn
Hospital. He had the following to say regarding theabortion issue:“Most of the patients that come to our hospital tohave an abortion are married women, women withproblems with the fetus or who come with excessive
bleedings due to self induced abortions. School girls
also come here a lot. These are patients I want to
help. We have seen a decrease in the abortion rate
at this hospital the last 4-5 years due to the easy
access to the pill Prostaglandins, actually a pill used
for peptic ulcer but which is now used as a pill toabort. It is cheap and can be purchased without aprescription anywhere at a pharmacy. We also
recommend our patients to use this.”Upon hearing that abortion is easy to attain in
Thailand with the pill available on the market
nowadays, we decided to try and buy the abortion
pill. We went to 15 pharmacies around Bangkok
without being able to buy it at all. Many of thepharmacists looked at us as they did not want
48th

The Nation (newspaper) (28 August 1997) “Call madefor update of abortion law”
49th
Thai Rath (1 September 2001) “Abortion in the 8month”
50
The Nation (English language newspaper) (9 September2001) “Horror abortion raises key questions”.

200

Eubios Journal of Asian and International Bioethics 20 (November 2010)

anything to do with this illegal matter, and one evendiscouraged us from attempting to abort due tokarmic reasons.
In conclusion, having an abortion in Thailand is stilla sensitive issue which needs to be given someattention to. The decision whether to have an
abortion or not should not be reasoned on thegovernment policies. Women need to be given a free
will to decide over their bodies. Perhaps as somehave said: “Laws against abortion does not stop itfrom happening, they simply make it unsafe”.

Castro (The Philippines), Ole Doering (Germany), Norio Fujiki(MURS Japan), Tran Han Giang (Vietnam), Thomas Gionis(USA), Dena Hsin (Taiwan), Rihito Kimura (Japan), Abby
Lippman (Canada), Margaret Lock (Canada), Umar Jenie(Indonesia), Nobuko Yasuhara Macer (Japan), Anwar Nasim(Pakistan), Mary Ann Chen Ng, (Philippines), Jing-Bao Nie(China, New Zealand), Pinit Ratanakul (Thailand), Qiu Ren
Zong (China), Hyakudai Sakamoto (Japan), Sang-yong Song
(Republic of Korea); Noritoshi Tanida (Japan), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republic ofKorea).

Conferences
References
Bamber, Scott (1997) „The Thai medical profession andpolitical activism‟, Political change in Thailand (p. 233250) Routledge.
Banhart, Michael G. (1998) „Buddhism and the morality ofabortion‟, Journal of Buddhist Ethics.
Bell, Peter (1992) Gender and economic development inThailand.
Lerdmaleewong, Malee (1998) “Abortion in Thailand: A
feminist perspective” Journal of Buddhist Ethics, Vol 5
1998: p. 22-48
Warakamin, S., Boonthai N., Tangcharoensathien V.,(2004) „Induced Abortion in Thailand: Current situation in
public hospitals and legal perspectives‟, Reproductive
Health Matters (24 Supplement): p. 147-156.
Whittaker, Andrea M. (2004) Abortion, sin and the state in
Thailand, Routledge Curzon.
Whittaker, Andrea M. (2002) „The struggle for abortion law
reform in Thailand‟, Reproductive Health Matters 10 (19):45-53.
Other newspaper articles:
Bangkok Post (15 March 1978) “200,000 abortions a year
in Thailand”.
Bangkok World (25 March 1978) “Three alleged
abortionists arrested”.
Naew Na (Thai newspaper) (10 April 1988) “Abortion law
crushes every religion?”.
Matichon, (14 April 1988) “All religions must strengthen to
oppose free abortion law”.
th
The Nation (newspaper) (28 August 1997) “Call made for
update of abortion law”.
The Nation (English language paper) (10 November 2001)“New abortion bill: Sex law stirs an uproar”.
Bangkok Post (3 February 2001) “Abortion law likely to beamended” by: Bhatiasevi, Aphaluck.
The Nation (14 November 2001) “Battle of the sexes allover again”.
Thai Rath (Thai newspaper) (26 April 1997) “Surprise
attack catching 7 clinics doing abortions”.
The Nation (English language newspaper) (4 Sept. 2001)“Police charge abortion girl”.
The Nation (English language newspaper) (9 September2001) “Horror abortion raises key questions”.
Krungthep Thurakit (Thai newspaper) (28 August 2001)“300,000 Thai women have abortions each year”.

EJAIB Editor: Darryl Macer
Associate Editors
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Managing Director: Anniken Celina Grinvoll
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Angeles Tan Alora (Philippines), Atsushi Asai (Japan),
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Editor: Darryl MacerApril 2000 ISBN 0-908897-16-2, 112pp. Cost: US$20 UK£12 NZ$30 A$30 C$30 ¥1000 NZ$35
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Bioethics and the Impact of Human Genome Research in the 21 Century
Eds: Norio Fujiki, Masakatsu Sudo, & Darryl R.J. Macer March 2001 (English and Japanese bilingual, 350pp).
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Cost: US$30 UK£20 NZ$40 A$38 C$40 ¥3000

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

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