pp. 103-106 in Bioethics in Asia

Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute

Copyright 2000, Eubios Ethics Institute All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with the author.

3.1. Doing Bioethics in the Philippines: Challenges and Intersections of Culture(s) and Medicine(s)

Peter A. Sy.

University of the Philippines, Quezon City, the Philippines

This paper briefly outlines:

1. the culture of bioethics as it bears on the thematization of health and illness in the Philippines,

2. the challenge that Filipino traditional medical views pose to bioethical discourse, and

3. the prospects of doing bioethics in the country.

Limited in space and scope, our discussion restricts "bioethics" to include only philosophical-ethical as well as cultural concerns related to medicine. Issues attendant to other spheres of "bios" like the environment are excluded.

At the core of this discussion is the importance of understanding the differences in medical and philosophical categories used by biomedicine and Filipino traditional medicine. Among other biomedical categories, "abortion," for instance, carries with it a whole baggage of "western" cultural biases that may conflict with traditional Filipino medical practices. Such recognition of medical or philosophical-ethical gap between the two medicines is crucial in attempts at forging workable paradigms for genuine cultural dialogues in the Philippines.

The Culture and Discourse of Bioethics

Biomedicine helps shape the contours and conceptual limits of bioethics. At risk of oversimplification, we may view bioethics largely as the ethics of biomedicine--an institution also known as "western allopathic medicine" usually distinguished from personalistic and naturalistic approaches to health and medicine (1). Although the term "biomedicine" has its own limitation and inadequacy, it is, nonetheless, used to emphasize the institutional structures of the dominant medical profession which invoke the primacy of certain scientific, philosophical, and ethical commitments not necessarily shared by Filipinos and other peoples of the world (2). Biomedicine is anchored on allopathic `germ theory' that tends to regard illnesses exclusively as enemies (3).

It is difficult, if not impossible, to just label biomedicine "Western," since it is already practiced worldwide and likely has nonwestern sources. Already a global institution, it is certainly the dominant practice in the Philippines. Biomedicine, which tends to be identified with biological thinking (itself far from being monolithic), forms the foundation of the country's formal health care system. From government policies to vaccination in the barangay, from court rulings to the conduct of rural health workers, from textbook writing to family planning, it is the basis of mainstream medical interpretations and interventions.

Biomedicine is, however, not just any bureaucratic justification or professional preoccupation, it is a cultural system--"a system of symbolic meanings on a particular arrangement of social institutions and patterns of interpersonal interaction" (4). It can be seen as a system of social control.

Biomedicine, as Kleinman asserts, is "a leading institution of industrialized society's management of social reality. Biomedical constructions of the various forms of human misery as health problems are reinforced by societal regulations that can influence all sectors of experience. This process of medicalization is responsible for certain of medicine's most controversial attributes. Biomedicine's sector of influence continues to grow as more and more life problems are brought under its aegis" (5). Biomedicine tends to be part of overall societal system of regulatory techniques and technological powers conditioning human choices and actions through the medical regimen (6).

In this light, bioethics (as we know it) is severely limited by the purview of biomedicine. Medicocentric, bioethical discourse privileges certain ethical principles in ways different from Filipino ethical constructions. "(T)he canonical works (of bioethics) assume an individuated self, set off from the collective--single, unchanging, self-defining. Thereby, inter alia, autonomy of the person is claimed to be a paramount value along with ideas of justice and beneficence" (7). Some western values like autonomy of persons, however, appear not as privileged as values like solidarity in Philippine society.

The Challenge of Traditional Medicines

"Traditional Filipino medicine" refers not to a single medical system. There are actually many Filipino medical systems (8)--owing largely to the diversity of the country's ethnic groupings (about 70) and the various colonial or foreign influences, especially European and Chinese. It can rarely be equated with "indigenous medicine," since there is no way we can identify which medical practices and beliefs are purely local. Traditional Filipino medicine pertains to dynamic and popular non-biomedical systems in the Philippines. It includes a wide range of practices of manghihilot (traditional bone setter), albulario (medicine man), acupuncturists, religious healers, etc.

The obvious strength of traditional medicine is number. There are more practitioners of traditional medicine than practitioners of biomedicine. The Philippines has at least 40,000 traditional birth attendants and 100,000 herbalists (9), in addition to other thousands of manghihilot, acupuncturists, etc. who are mostly concentrated in the rural areas.

Now pending in the Tenth Congress of the Philippines are bills seeking to institutionalize traditional medicine and alternative health care (10). These bills recognize the urgent need to incorporate traditional medicine into the `conventional' medicine. They point out the government's inability to meet the health care needs of the Filipino people and the country's over-dependence on foreign drugs which are not accessible to the poor who comprise 70% of the population. Some of these legislative measures propose the creation of a regulative body that will `oversee' the practice of traditional and alternative medicines. This move in the Philippine legislature, unfortunately, invites tension, not only because it divides policy makers and even biomedical practitioners into endorsers of the bills and their rabid opponents, but also because the government is trying to institutionalize practices which are essentially nonformalizable. The roles of traditional medical practitioners are broadly defined and informally assumed. There is little (if at all) professionalization in the field. Nor is there any strong institutional distinction between manghihilot, shamans, herbalists, and other practitioners of traditional medicine who nevertheless resemble a harmonious confluence of medical traditions.

The deeper challenge, however, lies in the cultural, philosophical and ethical views that inform traditional Filipino medicine. It has become increasingly clear that the deficiencies, if not failure, in the delivery of primary health care in the country are rooted in the misunderstanding of basic Filipino concepts of health and illness (11). Many attempts at classifying traditional, indigenous, and popular medical practices founder on "western" dichotomies between the natural and the supernatural, the metaphysical and the scientific, the spiritual and the bodily. Recalcitrant to classification are the inherent ambiguities of traditional Filipino medical, philosophical, and ethical categories.

In a study on acute respiratory illness, furthermore, it is asserted that "the folk epidemiology of respiratory illness is far removed from models of biomedical epidemiology. While the former focuses on factors rendering one vulnerable to illness, the latter investigates illness-specific pathogen-host-environment relationships" (12).

In a larger picture, many illnesses in the Philippines cannot be appropriated into biomedical pathology. Biomedicine fails not only because local ailments escape biomedical categories but also because the treatments that go with biomedical disease labeling tend to undermine certain philosophical-ethical persuasions of Filipinos. Many biomedical practitioners are too quick to label as medical problems what essentially are philosophical problems or differences in worldviews (13). Bioethicists, however, need to probe into ethical and philosophical underpinnings of Filipino traditional medical practices to understand how bioethical discourse can be truly informed of Filipino cultural ethos.

The abortion debate that proved to be very divisive in Europe and in the US can have a different spin in the Philippines if certain local practices and beliefs are highlighted. Some observers note the abundance of so-called "abortifacients" which, in Cebu (a major Philippine island) alone, are close to forty (14). As a term, however, "abortifacient" may be semantically, if not ethically, misleading because many locals take these concoctions as pamparigla (restoration of menstrual flow). The fetus (a biomedical category which appeared to have no indigenous equivalence before the coming of `imperial' medicine) or dugo (roughly "mass of blood") will come to life if it is really meant to be buhay (meaning "life" or "to survive"); hence, a phenomenon biomedicine may readily describe as "abortion" need not be morally controversial at all. Undeniably this underscores the importance of looking at the very categories bioethicists use. Without sifting through certain cultural and ethical biases latent in biomedicine, discussions of sensitive issues like abortion can be counterproductive.

For lack of space and time, the discussion of other traditional medical views and practices can only be excluded. The most popular ones include pasma (described roughly as profuse sweating, shaking of hands, exhaustion, or headache as a result of wrong interplay of "hot" and "cold"), kuyap (a Cebuano term to describe pulsations in the diaphragm accompanied by nausea), sumpung (loosely translated as passing phase or mood) to which some ailments like asthma are attributed, and hiyang (literally meaning "what fits") sometimes used to describe medical interventions that are suited to individual needs and temperaments (15).

My purpose here is obviously not to provide a systematic account of these traditional medical views and practices. I want to invite serious rethinking and reevaluation of the categories we use in doing bioethics in the Philippines.

The Prospects of Doing Bioethics in the Philippines

The challenge that traditional medicine pose to biomedicine and consequently to bioethics is not just the avoidance of what Kleinman calls "category fallacy"--i.e., "imposition of a classification scheme onto members of societies for whom it holds no validity" (16)--but also the sheer philosophical space these medicines open up for us.

The fact that Filipinos can pragmatically switch between paradigms in their pursuit of good health suggests intersections of cultural systems and logic. A viable ethics, therefore, can be formulated at the intersection of social logic of symbolic systems (like traditional medicine and biomedicine) and historical events. The Philippines' unique history and culture offer a complex of opportunities and challenges to the theory and practice of bioethics. Its long colonial history has brought about assimilation, among others, of so-called "western" ethical values which, rather than being fetters, may provide some flexibility in philosophical-ethical negotiations vis-_-vis technological encroachments and biomedicine.

Already recurrent in Filipino culture are themes of pluralism and pragmatism contrasting the exclusivism and dogmatism of biomedicine. It is, for instance, not uncommon for Filipinos to consult both the biomedical doctor and the mananambal/albulario (medicine man) or even for some doctors to prescribe drugs and advise their clients to seek supplementary attention from hilot (traditional bonesetter or masseur). Reportedly an eminent pediatrician sends her grandchildren to hilot for pilay (a traditional Filipino notion of bony, nervous or vascular dislocation). Some biomedical doctors recognize that popular belief in init-lamig ("hot and cold" principles) as causative factors in cough should be considered in the formulation of an effective and comprehensive ARI (acute respiratory infection) eradication program (17).

Needed, therefore, are ethical systems that respect this kind medical pluralism. Forcing the bioethical discourse into the Filipino culture may do more harm than good. Some academics call for integration of biomedicine and traditional/alternative medicine. But, more often than not, integration turns out to be a subsumption of the weak by the strong, of traditional medicines by biomedicine. The alternative to integration model is "osmosis"--the mutual absorption of good qualities of both biomedicine and traditional medicines as well as their concomitant ethical discourses. Let bioethics learn the vocabulary of Filipino ethics and Filipino ethics be nourished by biomedical experiences. Let medicines and ethical discourses flourish. This prospect is easier imagined than put to practice, but the choices aren't that many and time is running out. There are millions of suffering Filipinos.

References

1. Norman G. Owen, "Toward a History of Health in Southeast Asia" in N.G. Owen, Death and Disease in Southeast Asia: Explorations in Social, Medical and Demographic History (Oxford UP, 1987), 3-30.

2. Arthur Kleinman, Writing at the Margin: Discourse Between Anthropology and Medicine (University of California Press, 1995), 25.

3. Owen, loc. cit.

4. Kleinman, 8.

5. Kleinman, 38.

6. Simon J. Williams and Michael Calnan, "The `Limits' of Medicalization?: Modern Medicine and the Lay Population in 'Late' Modernity," Social Science and Medicine 42 (1996): 1609-20.

7. Kleinman, 46.

8. Michael L. Tan, Usug, Kulam, Pasma: Traditional Concepts of Health and Illness in the Philippines (Quezon City: AKAP, 1987), 89ff.

9. M.L. Tan, "Traditional Medical Practices in the Philippines," Health Alert 134 (1992): 277-290.

10. House Bills No. 2324, 4464, 7469, 7949, 7716, and 8145. n.p.

11. Tan, Usug, Kulam, Pasma: Traditional Concepts of Health and Illness in the Philippines, 1.

12. Mark Nichter and Mimi Nichter, "Acute Respiratory Illness: Popular Health Culture and Mother's Knowledge in the Philippines" in M. Nichter and Mimi Nichter, eds., Anthropology and International Health: Asian Case Studies (Gordon and Breach, 1996), 173-200.

13. Tan, op. cit., 13.

14. Elena Yu and William T Liu, Fertility and Kinship in the Philippines (Notra Dame UP, 1980), 137.

15. Tan, op. cit, 19ff.

16. Kleinman, 13.

17. Jessica Cueto, "Perception and Well-being," Health Alert 103 (1990): 125-6.


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