Leonardo D. de Castro

The declaration of Istanbul in the Philippines: success with foreigners but a continuing challenge for local transplant tourism

The Philippine government officially responded to the Declaration of Istanbul on Organ Trafficking and the related WHO Guidelines on organ transplantation by prohibiting all transplants to foreigners using Filipino organs. However, local tourists have escaped the regulatory radar, leaving a very wide gap in efforts against human trafficking and transplant tourism. Authorities need to deal with the situation seriously, at a minimum, by issuing clear procedures for verifying declarations of kinship or emotional bonds between donors and recipients. Foreigners who come to the country for transplants with same-nationality donors constitute a problem that is replicated in many transplant centers around the world. Also, emotionally related living donors continue to pose challenges for ethics committees, especially because of the realities associated with the existence of extended families. Those who find themselves facing these issues need to be armed with clear protocols for going through the process of verifying documents and individual declarations assiduously. There is also a need for international referral mechanisms at least to ensure that governments are aware when their citizens travel for transplant so they can take steps they consider suitable to address the vulnerabilities of exploited persons.

Transporting values by technology transfer.

The introduction of new medical technologies into a developing country is usually greeted with enthusiasm as the possible benefits become an object of great anticipation and provide new hope for therapy or relief. The prompt utilization of new discoveries and inventions by a medical practitioner serves as a positive indicator of high standing in the professional community. But the transfer of medical technology also involves a transfer of concomitant values. There is a danger that, in the process of adopting a particular technology, the user takes for granted the general utility and desirability of the implements and procedures under consideration without recognizing the socio-cultural peculiarities of the adopting country. A sensitivity to the social conditions and cultural traditions is important so that the emergence of new values can be examined critically and the transfer of necessary technology can be effected smoothly. In the Philippines, efforts to boost patronage of transplant technology appear to have overlooked this need for socio-cultural sensitivity. Legislative fiat cannot be used to override deep-seated values. There is a need to be more sensitive to the possible confrontation of values that the transfer of technology brings in order to avoid the erosion of indigenous socio-cultural values and minimize the intrusiveness of beneficial medical technology.

The UNAIDS Guidance Document: A Statement Against Using People

This commentary on the guidance points contained in UNAIDS Ethical Considerations in HIV Preventive Vaccine Research (Guidance Document) presents an interpretation of the guidance document as a statement against `using people in research. In support of this view there is a discussion of selected concepts that are touched upon in the UNAIDS document and in other international guidelines on research involving human subjects. Even as we accept that the use of human subjects in research inevitably involves `using people it is important to draw the Kantian distinction and ensure that human subjects are not `merely being used. For us this means ascertaining at least two things ± that people are not being used without their knowledge and consent and that they are not being used in a way that has no direct benefits for them. (excerpt)

Research Ethics, Cross-Cultural Dimensions of

This article is a revision of the previous edition article by D. Tuzin, volume 3, pp. 13231–13235,

Raising Questions about an Ideological Approach to Bioethics Discourse in Asia

In this issue, one finds in the main articles an emphasis on patients as individuals who are intimately connected to relational structures that clinicians and/or health systems need to take into account in order to achieve the best overall outcomes for them. While acknowledging the importance of recognising this connectedness, particularly in Asian contexts, the authors also appear mindful of the need to prevent patients’ best interests from being obscured by the demands of larger entities such as families, communities or health systems. In The Benevolent Polity: A Confucian Socio-Ethical Vision of Eldercare, JingBao Nie asserts that Confucianism has long been misrepresented by the Chinese state as advocating the subordination of the interests of the individual to those of the collective. He argues that the misrepresentation has played a significant part in the failure of the state to provide adequate care of the elderly. Drawing particularly on the teachings of Mengzi (Mencius), a key contributor to the development of classical Confucian philosophy, he shows how Confucianism requires benevolent governance as a consequence of its emphasis on the dignity of the person and its sensitivity to the needs of the vulnerable. The Human Spirit and Responsive Equilibrium: End of Life Care and Uncertainty by Grant Gillett, Maeve McMurdo and Jing-Bao Nie looks at the challenges of providing end of life care in situations of uncertainty about how patients will respond to treatments. They emphasise the importance of physicians’ attentiveness to the significance of the human spirit and their willingness to engage in an open-ended dialogue with patients and their families about appropriate courses of action. While acknowledging variations in treatment preferences across cultures, they emphasise the universal relevance of the fundamental human considerations they espouse, pointing to a correlate of the Western concept of spirit, or essence, within the Chinese philosophical concept of shen that is central to the practice of traditional Chinese medicine, and to the importance of the Confucian concept of ren, sometimes translated as “benevolence”, in

Bioethics Education in Resource-Challenged Countries

Bioethics education in resource-challenged countries has been enriched by international collaborative networking and capacity-building support. Doing bioethics education in resource-challenged countries involves a need to continually balance culturally appropriate and culturally responsive methods of teaching bioethics in the context of preconditions and demands that come along the provision of external aid.

Commercial Surrogacy, Compensation for Research Participants and Other Arguments for Public Education in Bioethics

This issue of the Asian Bioethics Review contains articles on topics that remind us of the need for comprehensive — and democratic — bioethics education. The two essays on assisted reproductive techniques and surrogacy highlight a need for more guidance in terms of legal regulations or guidelines in India and Japan. The necessity for legislative updating and thus, for public consultations regarding specific proposals, leads us to query the nature, objectives and adequacy of consultations that have to be undertaken. The article on undue inducement for participation in clinical trials in the Philippines points in the same direction. While the author does not contemplate legislation as a way to resolve differences in approach and practice, he recognises the importance of finding a way forward within the context of local culture and traditions. Thus, extensive community consultations would appear to be a minimal requirement for an exercise that would enable participants to search within themselves for culturally-informed validation of pertinent proposals. The yearning for more definitive regulatory or legal guidance has to be sorted out. One way to address this is to pass legislation that provides definitive guidance where not yet available, or that which plugs discernible loopholes in existing regulations. In either case, the introduction of legislation requires preparatory public consultations to determine the views of experts and the sentiments of the general public concerning the practices under consideration. This editorial takes the view that public consultations about important issues related to these topics should take the opportunity to profit from

Commentaries from Different Perspectives: Even in the Face of Similarities, Differences Matter

The various commentaries in this issue’s Case Corner illustrate once again how different perspectives can sometimes lead to very similar conclusions. Coming from different cultural and professional backgrounds, the commentators share with the readers different ways of approaching the case and appeal to considerations that are similar in some respects but dissimilar in others. One approach described in the commentaries comes from Darwish of Egypt: “In deciding for an incompetent patient, or even for themselves, most members of families appeal to their attendant physicians to decide ...” But this is paternalistic deference with a religious flavour: “They think that their physicians better know the governing laws and the Islamic Sharia rules for their case, ... and Islamic Sharia in most cases affects and shapes the ethical and legal responses to the ethical challenges of medicine.” This does not mean that the physicians are regarded as religious authorities. There is merely a presumption that they have greater familiarity with the Sharia rules pertaining to cases associated with their medical practice. At the end of the day, people may doubt the reliability of a physician’s verdict on a particular case and consult a religious scholar. But it is interesting to note the concentration of authority that may be vested in physicians in a setting where the patient and the family turn to them not only for medical advice but also for presumptive religious knowledge. The commentator also observes that Egyptian society is not only paternalistic but also masculine. Thus, “if the incompetent patient is the husband, the decision can be his brothers’ or the father’s,” rather than that of the wife,

Patient Vulnerability and Professional Vulnerability

The papers in this issue of the Asian Bioethics Review may be seen to have a common thread in being commentaries, directly or indirectly, on situations of vulnerability and the way in which vulnerabilities bear on the ethical issues arising. The varying situations illustrate various aspects of vulnerability. Vulnerability has often been discussed in bioethics in terms of groups of vulnerable populations. Groups of patients or research subjects are seen to have various types of weaknesses that render them exposed to exploitation or unfair treatment. For example, children have been singled out as belonging to a vulnerable population. Thus, they need to be regarded with additional care compared to non-vulnerable populations who are capable of deciding and speaking for themselves either as patients or as subjects of biomedical research. In this issue of the ABR, the paper by Siriwardhana et al., highlights the plight of survivors of a natural disaster. The paper mentions the threat of possible exploitation of vulnerable survivors by unscrupulous researchers. One can imagine thousands of survivors being interviewed or publicly observed several times by investigators wishing to take the opportunity to document the experiences of disaster victims not only in writing or in subsequent publications but also through audio and video recordings. Some of the audio and video accounts are also broadcast to the rest of the world as part of news accounts of a tragedy. Some of these accounts are not mindful of the dignity of victims. In addition to the vulnerability of disaster victims, the vulnerability of researchers also needs attention. Enthusiastic as they are to pursue their calling in their field of expertise, many researchers feel the need to conduct studies in the context of a disaster. Their vulnerability lies in their predisposition to

Sakit and Karamdaman: Towards Authenticity in Filipino Concepts of Disease and Illness

This paper aims to highlight the value of authenticity in responding to disease and illness. The argument is that authenticity must be added to utilitarian and pragmatic considerations as a criterion of the validity of healing responses to disease and illness. Authenticity may be achieved by ensuring the alignment of treatments and remedies with the social and cultural dimensions of concepts of disease and illness. The point is that diseases and illnesses are not merely biophysical phenomena. They form part of a matrix of values, traditions and beliefs that define a cultural identity.