asian bioethics: challenges and prospects in the coming decade leonardo d. de castro, ph.d....

Asian Bioethics: Asian Bioethics: Challenges and Challenges and Prospects in the Prospects in the Coming DecadeComing Decade

Leonardo D. de Castro, Ph.D.University of the Philippines

Vice Chair, UNESCO International Bioethics CommitteeSecretary, International Association of Bioethics

L DE CASTROUNIVERSITY OF THE PHILIPPINES

UNESCO GLOBAL ETHICS UNESCO GLOBAL ETHICS OBSERVATORYOBSERVATORY

Mongolia

KyrgyzstanKazakhstan

Turkmenistan

Tajikistan

Afghanistan

Nepal

Myanmar Lao PDR

Papua New Guinea

North Korea


Challenges of Asian BioethicsChallenges of Asian Bioethics

The challenge of identityThe challenge of identity

The challenge of regional The challenge of regional integration – growing integration – growing together together

The challenge of povertyThe challenge of poverty

What is Asian about Asian What is Asian about Asian bioethics? How do we bioethics? How do we maintain our identity?maintain our identity?

How do we face the How do we face the problems that concern us problems that concern us all?all?

How do we use bioethics How do we use bioethics to break the bonds of to break the bonds of poverty?poverty?


ASSERTING UNIQUENESSASSERTING UNIQUENESS


ASSERTING ASIAN ASCENDANCYASSERTING ASIAN ASCENDANCY


AN ASIAN PERSPECTIVEAN ASIAN PERSPECTIVE


ASIAN PERSPECTIVESASIAN PERSPECTIVES


AN ASIAN PERSPECTIVEAN ASIAN PERSPECTIVE


SOME UNIVERSAL CONCEPTS?SOME UNIVERSAL CONCEPTS?


WHAT IS ASIAN ABOUT ASIAN WHAT IS ASIAN ABOUT ASIAN BIOETHICS?BIOETHICS?


HOLISTIC HARMONY?HOLISTIC HARMONY?

““the essence of the Asian ethos is . . . ‘a the essence of the Asian ethos is . . . ‘a holistic harmony’ in contrast to the modern holistic harmony’ in contrast to the modern European inclination to dualistic European inclination to dualistic individualism.” (Sakamoto, 1999) individualism.” (Sakamoto, 1999)


RESPONSIBILITY-ORIENTED?RESPONSIBILITY-ORIENTED?

The standard [Western] ethical framework is The standard [Western] ethical framework is inadequate in other aspects. It always talks inadequate in other aspects. It always talks about rights, but much less about about rights, but much less about responsibility, and the principles seem to be responsibility, and the principles seem to be put forth a priori and applied to any cases, put forth a priori and applied to any cases, regardless of the context of their application. regardless of the context of their application. (Wang, 1997)(Wang, 1997)


RELIGIOUSITY OR SPIRITUALITY?RELIGIOUSITY OR SPIRITUALITY?

In contemporary Western bioethics In contemporary Western bioethics discourse, the abortion debate has been discourse, the abortion debate has been closely associated with the discussion of closely associated with the discussion of personhood . . . . In summary, while personhood . . . . In summary, while Confucianism does not hold an absolute Confucianism does not hold an absolute prohibition on abortion as does the Roman prohibition on abortion as does the Roman Catholic Church, the general attitude of Catholic Church, the general attitude of Confucianism toward abortion is not as Confucianism toward abortion is not as significantly different from those of other significantly different from those of other major world religious-moral traditions such major world religious-moral traditions such as Judeo-Christianity, Islam, and Buddhism as as Judeo-Christianity, Islam, and Buddhism as usually assumed. (Nie, 2002)usually assumed. (Nie, 2002)


FAMILY-CENTERED?FAMILY-CENTERED?

The The WesternWestern principle of principle of autonomy is an autonomy is an individual-orientedindividual-oriented principle. It requires principle. It requires that the patient, as long that the patient, as long as being competent, as being competent, have the final authority have the final authority to make clinical to make clinical decisions for himself. decisions for himself.

In contrast, the East In contrast, the East Asian principle of Asian principle of autonomy is a family-autonomy is a family-centered principlecentered principle. The . The principle implies that principle implies that the entire family, rather the entire family, rather than the individual than the individual patient, should have the patient, should have the final authority over final authority over clinical affairs. (Fan, clinical affairs. (Fan, 1997)1997)


PATERNALISTIC & HIERARCHICAL?PATERNALISTIC & HIERARCHICAL?

. . . . . . paternalistic and hierarchy-orientedpaternalistic and hierarchy-oriented behavior patterns are deeply ingrained in the behavior patterns are deeply ingrained in the Japanese medical system. Japanese medical system.

rhetoric drawn from Confucian tradition was rhetoric drawn from Confucian tradition was used to . . . reinforce that tendency in used to . . . reinforce that tendency in doctors. doctors.

But . . . But . . . tradition can be modified and tradition can be modified and enrichedenriched, (Hamano, 1997), (Hamano, 1997)


IMPORTED?IMPORTED?

It is fair to say that biomedical ethics in Japan It is fair to say that biomedical ethics in Japan developed in the wake of the West, developed in the wake of the West, particularly that of the United States. The particularly that of the United States. The first phase of Japanese biomedical ethics, as first phase of Japanese biomedical ethics, as we define it, was largely “an importation of we define it, was largely “an importation of Western biomedical ethicsWestern biomedical ethics.” (Akabayashi and .” (Akabayashi and Slingsby, 2003, p. 261) Slingsby, 2003, p. 261)


IMPORTED?IMPORTED?

Use of DNA samples from the Republic of Use of DNA samples from the Republic of Tonga to study diabetes. Tonga to study diabetes.

Urge Australian researchers and the Urge Australian researchers and the government -- to consider government -- to consider responsibilities responsibilities beyond our shoresbeyond our shores where research is aimed where research is aimed at benefiting our populace. (Ankeny, 243) at benefiting our populace. (Ankeny, 243)


WHY ASK ABOUT ASIAN WHY ASK ABOUT ASIAN BIOETHICS?BIOETHICS?

Rock-bottom questionsRock-bottom questions about life and death about life and death require require rock-bottom reflectionsrock-bottom reflections about the about the origins of our values and the foundations of origins of our values and the foundations of our respective culturesour respective cultures


GROWING TOGETHER: GROWING TOGETHER: COPING WITH COMMON ISSUESCOPING WITH COMMON ISSUES


ORGAN DONATION AND ORGAN DONATION AND TRANSPLANTATIONTRANSPLANTATION


Given the rapid advances in transplant Given the rapid advances in transplant technology, the capacity of doctors to technology, the capacity of doctors to perform successful transplants has also perform successful transplants has also improved considerably. This has led to even improved considerably. This has led to even greater demand, thereby putting a lot of greater demand, thereby putting a lot of pressure on the supply. As a consequence, pressure on the supply. As a consequence, the illegal sale of human organs has also the illegal sale of human organs has also flourished. flourished.


Transplant murder?Transplant murder?


Cultural change cannot be Cultural change cannot be legislatedlegislated


Donor-Donor-middlemamiddlema

n:n:


Understanding values in contextUnderstanding values in context


Kidney Donor or Kidney Seller?Kidney Donor or Kidney Seller?


Prisoners and organ transplantsPrisoners and organ transplants

Death convictsDeath convicts

Premature declaration Premature declaration of deathof death

Kidneys for life?Kidneys for life?


WHAT CAN WE DO?WHAT CAN WE DO?

The “portability” of human organs is a very The “portability” of human organs is a very strong argument for broad bioethical strong argument for broad bioethical reflection that transcends national reflection that transcends national boundaries. boundaries.

Avoid circumvention in national regulations Avoid circumvention in national regulations that could not be enforced outsidethat could not be enforced outside

Responsibility of donor and recipient Responsibility of donor and recipient countries alikecountries alike


BIOETHICS AND POVERTYBIOETHICS AND POVERTY


Annual expenditure on health per capita Annual expenditure on health per capita (Intl $)(Intl $)

0

200

400

600

800

1000

1200

1400

1600

1800

JapanAfghanistan IndiaSri Lanka


Health expenditure as percentage of GDPHealth expenditure as percentage of GDP

0

1

2

3

4

5

6

7

8

JapanAfghanistanIndiaSri Lanka


Life expectancy at birthLife expectancy at birth

0

10

20

30

40

50

60

70

80

90

Male Female



Health professional / 100,000 populationHealth professional / 100,000 population

0

100

200

300

400

500

600

700

800

Doctors Nurses



The poorThe poor

The poor have less The poor have less knowledge knowledge

fewer resources and fewer resources and

less power to defend less power to defend their healththeir health

The poorer the country, The poorer the country, the less it spends on the less it spends on protecting and protecting and promoting the health of promoting the health of its population its population

(Global Forum for Health Research, 2002)(Global Forum for Health Research, 2002)


A moral necessity!A moral necessity!

That governments and international agencies That governments and international agencies take bold steps to minimize the prevailing take bold steps to minimize the prevailing injustices and ensure that poor people are injustices and ensure that poor people are not left at the mercy of market forcesnot left at the mercy of market forces


Controversial responses to the Controversial responses to the challenge of povertychallenge of poverty

the infringement of drug patents in the infringement of drug patents in emergencies, emergencies,

the purchase of cheap counterparts of locally the purchase of cheap counterparts of locally manufactures drugs and medical supplies manufactures drugs and medical supplies from countries with permissive patent laws, from countries with permissive patent laws,

or the licensing of local generic or the licensing of local generic manufacturers to make drugs more cheaply. manufacturers to make drugs more cheaply.


People are dyingPeople are dying

From diseases like AIDS, tuberculosis, From diseases like AIDS, tuberculosis, sleeping sickness and other tropical diseases sleeping sickness and other tropical diseases

Because life-saving essential medicines are Because life-saving essential medicines are either too expensive either too expensive

o Due to patent protection, orDue to patent protection, or

o Not available because they are not seen to be Not available because they are not seen to be financially viable by the pharmaceutical financially viable by the pharmaceutical industryindustry

(Medicins sans frontieres, 1999)(Medicins sans frontieres, 1999)


HIV/AIDS HIV/AIDS VACCINE?VACCINE?

AIDS experts: the only AIDS experts: the only effective solution to the effective solution to the rapid spread of the rapid spread of the epidemic would be an epidemic would be an AIDS vaccineAIDS vaccine

So

No serious investments in

vaccine research

But

AIDS vaccine would AIDS vaccine would yield lower profit yield lower profit compared to compared to therapeutic drugs therapeutic drugs (drugs that treat rather (drugs that treat rather than prevent infection) than prevent infection) already in the market in already in the market in developed countriesdeveloped countries


Effect of patents on prices Effect of patents on prices


DENSITY OF HEALTH DENSITY OF HEALTH PROFESSIONALS & MORTALITY PROFESSIONALS & MORTALITY

RATESRATES


IMPACT OF MIGRATION ON IMPACT OF MIGRATION ON MORTALITYMORTALITY


MISSING WOMENMISSING WOMEN


Sex SelectionSex Selection

Mandatory control of family size has given Mandatory control of family size has given rise to gender preferences that, more often rise to gender preferences that, more often than not, has been manifested in a desire to than not, has been manifested in a desire to have male children. have male children.

Sex selection usually stems from the cultural Sex selection usually stems from the cultural climate & societal pressure of the nation, climate & societal pressure of the nation, rather than the individual mindsets of the rather than the individual mindsets of the parents themselves (Ruffolo & Wongboonsin, parents themselves (Ruffolo & Wongboonsin, 1995).1995).


SELECTION AND DISCRIMINATIONSELECTION AND DISCRIMINATION

This preference for children of a certain This preference for children of a certain gender, usually male, will lead to sex gender, usually male, will lead to sex discrimination, sex-selective abortions, discrimination, sex-selective abortions, female infanticide, deterioration of the female infanticide, deterioration of the quality of life for females, quality of life for females,

and may even have effects on the future and may even have effects on the future fertility & gender balance of the nation fertility & gender balance of the nation (Ruffolo & Wongboonsin, 1995).(Ruffolo & Wongboonsin, 1995).


MISSING WOMENMISSING WOMEN

29 million to more than 50 million missing 29 million to more than 50 million missing women in China. women in China.

For India: 23 million. (Sen, 2000) For India: 23 million. (Sen, 2000)

Need to reverse the social factors that could Need to reverse the social factors that could account for the lopsided figures – not only in account for the lopsided figures – not only in the sense of numbers but also in the sense of the sense of numbers but also in the sense of having been left out in the distribution of having been left out in the distribution of health care and other necessitieshealth care and other necessities


Grand challenge to bioethicsGrand challenge to bioethics

Allocation of health care resources and its Allocation of health care resources and its impact on the rights of people to basic impact on the rights of people to basic human needs human needs

Ensure that science and technology are put Ensure that science and technology are put in the service of promoting public health and in the service of promoting public health and of equalizing access to healthcare and of equalizing access to healthcare and medicines.medicines.

asian bioethics: challenges and prospects in the coming decade leonardo d. de castro, ph.d....

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