pp. 169-171 in
Bioethics in Asia
Editors: Norio Fujiki and Darryl R. J. Macer, Ph.D.
Eubios Ethics Institute
Copyright 2000, Eubios Ethics Institute
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Discussion on Bioethics Education
Macer: This session is on international education and ethics. The first speaker is Dr Crawley. Thank you, as you concluded, education is a very powerful instrument. We have five minutes for discussion.
Zion: In Australia there is debate about whether membership of ethics committees should be a paid position, and whether or not there should be education for the persons who will be on those committees, because the way in which they are chosen is often ad hoc. Do you have any comments?
Crawley: There is a lot to be said about that. First with respect to how we chose members of ethics committees, and secondly how we employ or compensate members of ethics committees for their work. The debate is also going on widely in Europe, as elsewhere. The question how we compensate people for the time they spend reviewing the enormous number of protocols. Another concern, perhaps in the context of this conference, is what is the best practice for ethics committees in different types of environments. This is a concern that I know the WHO is involved with at the moment, in developing texts for ethics committees in developing countries, and the Council of Europe with the European Commission is working on for improving the structure of ethics committees in Central and Eastern Europe. As you rightly say, whether it be in Africa or Asia, Japan or China, or Central or Eastern Europe, there are many problems with ethics committees we see in Europe, North America and Australasia as well.
Pinto: You mentioned that traditional schooling and academic courses were falling short, as far as I know, most universities in Europe are not teaching bioethics as a formal Chair, unlike what I have heard during this meeting. What kind of proposals do you have as a member of the UNAIDS? Have you proposed anything regarding this subject?
Crawley: I think it is good to have chairs in bioethics. One question might be in which faculty would it be? In philosophy or theology or life sciences or medical sciences? That is one question, but I also wonder, and one of the points of my paper was, is the academic setting the most appropriate? Dr Tan has hinted at this today, for medical students we may not need so many bioethics courses within their medical program, but within their residency years.
Leavitt: Just continuing this point, ideally we should do everything for free and voluntarily, but there is a limit to what you can do this way. In my own country in all the medical schools or life science faculties there may only be one bioethics position paid by hard money. If it is taught in a philosophy department then the information does not get to the medical school, unless they accidentally sign up for a non-elective course, which is very rare. In the nursing schools, medical schools and life science faculties there is much bioethics being taught, but they are doing it on all sorts of soft money or temporary positions. We have to face this problem, and pool resources internationally, if bioethics is going to be a genuine profession.
Crawley: It is not in my mind an academic problem, what is unique about ethics committees, perhaps different to bioethics, is that they have opened up places in society for discussions about morality and ethics in a unique place that did not exist before. It is outside of the university, outside of governmental structures and outside of traditional institutional structures, but it is a place that allows this kind of multidisciplinary plurality and education.
Macer: Thank you very much. One of the strong messages of the UNESCO International Bioethics Committee is to work on international education, and perhaps one of the main outcomes of the IBCfs work of the last few years will be the development of educational materials and promotion of education in many countries of the world. We hope we can work with many people in many countries of the world together. The next paper is from Dr Hirayama. Thank you for the interesting paper, and one of the purposes you mentioned for education to remove the prejudices and misunderstandings that we have in our society. Are there any questions?
Pinto: You mentioned that your data did not match the studies of UNICEF. I know that UNICEF is focusing on certain groups, and especially children, so what age range did you use, and did they include handicapped persons.
Hirayama: We surveyed four countries, India, Thailand, China and Japan. We have only quoted data of UNICEF for comparison of each background.
Macer: Dr. Hirayama and colleagues also made some comparisons to other studies, and there are a few contradictions which may need further studies to clarify in the future.
Begum: I would like to know what you mean by body and soul, what is the difference?
Hirayama: This is my own thinking, it is difficult. The body and soul have different meanings in every religion.
Begum: In all religions body and soul are different, but here we should use the view of rationality or science. I am a little confused.
Hirayama: I read the book by Ecqhurst, a brain physiologist who used an analogy that the brain is a kind of computer and the soul might be created by God. In Downfs syndrome the brain, or computer, is impaired, but the soul may be healthy. Ecqhurst wrote this about the evolving human brain in his book.
Begum: If someone does not believe in that, how do you explain this to them?
Hirayama: It is a matter of faith, so it is difficult.
Macer: In this conference people have observed that we are mentioning the soul and religious concepts more than in Western meetings, so we should come back to this theme. But, right now we must move to the next paper, by Dr Miyasaka. Thank you, and now we can take questions.
Sasaki: I would like to thank you for the very interesting presentation, and I would like to ask two questions. One is that you are talking of the possibility of a national exam for bioethics, but I wonder what sort of question is required for bioethics? Is it multiple choice, and what is a correct answer? Also you considered child donors for organ transplantation, under 15 years old. Why is it important under 15 years, is it because they are not old enough for autonomous decision making?
Miyasaka: The situation in Japan is that the national examination could ask students in which situation is informed consent required. A choice of four possible answers, but I think this is useless for bioethics thinking.
Sasaki: Is this because there is no recommended answer?
Miyasaka: Yes they do have a recommended answer, which is gIn all situationsh. For the second point, I am not saying children under 15 years do not have rights to decide, but this is another ethical question.
Sasaki: If you talk about bioethics, it is a kind of imported idea. If it is from American bioethics it is important to consider individual autonomy or individual decision, so you must create another standard if we consider under 15 years as different.
Miyasaka: The new organ transplantation law in Japan has the age of 15 years written, and the reason given for why the child under 15 years cannot donate is that they do not have competence to express their will. It is not my view, it is the lawfs view.
Leavitt: I think the point that more interdisciplinary study in bioethics is very important, because everything you said, including the study for the national examination, is exactly true in Israel as well. We all have to admit that our education is too narrow for bioethics, and we have to supplement it from other fields. As a philosopher, I find talk about genes and molecular biology difficult to follow, and people with a strictly scientific education find it difficult to talk about the soul, and God. We have to complete our education and learn from one another. The other point is that I donft think that you need strong bioethics courses in the medical school, rather we try to teach bioethics to the medical students over six years, with a few hours each semester. If you do it in conjunction with clinical rounds, which in Israel start in the first year, then you can teach the ethics in a situation where it will be extremely relevant. That is the direction we are trying.
Fluss: I would like to ask you a question which relates to a meeting the WHO organized in 1994, on the teaching of medical ethics in medical schools. There was consensus at almost every point, with one exception. That was do you allow the student who fails the examination in medical ethics to graduate and become a qualified medical practitioners. I was the only layman privileged to attend this meeting of 30 physicians, which included some representatives of Asian medical associations. It was impossible to get a consensus on this. What do you think?
Miyasaka: In the Japanese environment, many professors do not appreciate to think of evaluating bioethics education, so there is no standard to judge whether students can pass the course or not. This is the general atmosphere in Japanese schools.
Macer: Thank you very much for the discussion. Before Dr Shirahama speaks, I would like to have a mid-session summary of this session to see where we are going. We have just been discussing education of medical students. Before this we discussed the community in general, and later we will discuss school students. The role of a bioethicist in education is becoming very important, to take the discussion away. In this session we have several persons that we could say are the second generation of bioethicists in Japan. We are developing the education of bioethicists and we could call it the second wave of people involved in bioethics in Japan.
Let us continue the next speaker is Dr Shirahama. We can have some questions, and please leave your figure on for discussion.
Asada: Thank you for the informative presentation, and I have a comment and question. The 4-box figure is interesting. I think the goal of bioethics education is for students to search out for principles or ways to talk to others, so I am afraid that concerning the nature of Japanese students, the students may only attempt a logical game to try to fit their ideas into these boxes. But at the same time it is useful for starting discussion to have this method. I wonder whether you have some extra or additional aid for students for them to think beyond these boxes.
Shirahama: I agree that these boxes are only a tool to think, and not the final goal. The importance of our clinical ethics education is that the students find the case and then they present the case, so this experience is very important. If we only present our cases then it is like a game.
Asada: When they brought some cases, do they think according to only these boxes, or is there any other method?
Shirahama: No, I have only used this method, because it is very easy to teach within a short time. This covers a large amount of medical education. Students are usually only considering the medical indications box, so I suggest they consider the other boxes.
Leavitt: This is one of the best lectures in clinical ethics education, and I am very interested in what you said about Ikigai, the meaning of life. We are having a number of seminars in Israel on the meaning of life in clinical ethics education, which is different from the quality of life. I would like you to expand on two points, first what is meant in Japanese by Ikigai, because the word is new to me. My second question is that one of the biggest problems confronting nurses and doctors is what do you do when you have found a patient who has lost the meaning of life? Who finds no more meaning in life? What can you practically do to help to them find the meaning of life again.
Shirahama: I am a primary care physician in a rural village, and every person who is bed ridden can still help the spouse to do some work while in bed. Some people can pray in bed. About Ikigai, the medical people must find every personfs meaning of life.
Tanida: I am very interested in the presentation. About the 4-boxes, and conceptual features, you mentioned that harmony might be better in Japan than justice or utility used in North America, but what concerns me is that harmony is really the centre of Japanese ethics or culture, but it is really something which suppresses the dignity of the individual and the rights of Japanese people. So I would still prefer justice or utility, and the other terms are appropriate.
Shirahama: I agree harmony may be the centre, but in my practice if there is no harmony not only the patientfs preference, but also the familyfs preference, need to be harmonized.
Tanida: I agree about harmony, but what we need in justice in Japanese society.
Shirahama: Justice is very difficult, as discussed in the Tsukuba Bioethics Roundtable. There is local justice, but I need to think further.
Sasaki: What do you mean by Asia? In the four boxes you set a framework which may lead to what in sociology is called misrecognition. You may misrecognize some issue which is outside of these four boxes, or not recognize an issue outside of these boxes. Although you mention you can modify, if you create this kind of setting, it is very difficult to avoid the misrecognition. These four boxes already have an original standpoint, it has already embedded some epistemological or philosophical ideology from America. How can you avoid this?
Shirahama: While this theory may narrow our thinking, depending on the case discussion, it can be used as much as appropriate, and I will try to think of additional things that are still excluded. I will continue to revise this framework for discussion among different personalities.
Macer: Thank you, we must continue with the next talk, by Yukiko Asada and myself. We have some time for questions.
de Castro: I am wondering what the impact of bioethics education may be for class time for high school students. Do they have to spend more time at school, or do teachers have to spend more time at school, if this is in the curriculum. What is the impact? Will it be in the curriculum, and what are the plans for the future?
Asada: A couple of years ago, the Ministry of Education in Japan includes bioethics as a topic in the Ethics course and textbook. We have national standard textbooks and there are some sentences about bioethics, but usually it is just one sentence for the advantage and one on the problems. That is not enough. Also time limits in the curriculum are a major problem faced by many teachers. In the future we hope to make and suggest a concrete program to the Ministry of Education, but the time it takes to change the curriculum is very long, so teachers are trying to do what they can do now.
Daniels: I am interested in the content and the process. Particularly with regard to the process, can you can comment on the part that gender played for people to enter into discussion. What was the make up of the group gender wise?
Asada: Unfortunately we do not have many female members yet, but it high schools we do not have many female teachers in Japan. Maybe it represents the gender ratio of schools in general. Usually as we can observe in university and high schools, female teachers are very enthusiastic, and they do not hesitate to participate in discussions, and I would also like to introduce some perspectives of feminism into the discussion.
Macer: We are still analyzing the results of the survey of teacher network members so we hesitate to make conclusions yet. In the International Bioethics Education Survey only 10% of the teachers who responded were female, and in the network about 20% are female. Perhaps it is difficult to change the curriculum through the Ministry of Education in all countries, but they have been supporting development of individual teacher initiatives through this project to make a network, and I have received funding for 6 years for this project. The next paper is by Dr. Morioka. Thank you, we have some time for questions.
Zion: I wanted to ask you why in the account of abortion there is a strong womenfs movement, but there is still lack of availability of female contraception. There is not only lack of the birth control pill, but other female methods also. Why did this feminist movement not overcome this lack of contraception?
Morioka: The womenfs groups have tried from the beginning also, to ask the government, and in a few years we can expect the long term fight to succeed.
de Castro: Even if we assume that there are basic fundamental human rights to be observed by all, universal, donft you think that there are enough differences between culture that will render each culture unique, and therefore make the interpretation of fundamental principles vary between culture. Therefore the commonness of the fundamental principles would be in name only and not in meaning.
Morioka: Yes, it may be so. I lack enough research on this.
Macer: While there may be some differences, it is not so fundamental to say that fundamental human rights are not recognised in Asia, as some people argue. This is the conclusion of Mr. Morioka.
Fluss: The inter-relationship between what you call fundamental human rights and universal human rights and bioethics, in the West is not as tight as you seem to imply. If you go back to the history of bioethics, and some would say that the seminal events were in Seattle in 1962, I do not think that human rights played a role at all in those events and what happened subsequently. The early writings of Van Potter at the University of Wisconsin and the writings of people at the Kennedy Institute of Ethics did not talk about human rights. The five volume of Encyclopedia of Bioethics, revised edition, there is no entry for human rights, and there is no references to the International Covenants or Treaties on Human Rights, so that relationship is not as close as you have implied. I do not think that bioethics is so intimate,
Morioka: Thank you for the information. In Japan, the fundamental human rights came very recently, so it is new here.
Leavitt: I never notice a great deal of respect for human rights in the West, the Tian men Square shooting in China was merely imitating the long tradition in North American bioethics of shooting peaceful demonstrators against the Vietnam War in the 1970s or workers demonstrators, 100 years ago. All over the world there is disrespect for human rights. My question is whether if Japan internationalizes will it be to Japanise all these ideas, just like you adopted Chinese characters but in a very Japanese way. You adopted Buddhism from China and India but turned them into very specific Japanese ways of thinking. This may happen in bioethics, but in a uniquely Japanese way.
Morioka: Probably you are right, but you have to note that contemporary Japanese animation and karaoke, are exports of culture. So there are some imports and some exports of popular culture.
Kishore: It may not be wise to divide bioethics into Eastern and Western, because if we see the Western scenario, there are differences in all the controversies. Let us take the case of abortion, Canada is ruled more by the Charter of Freedom, whereas in the USA they approach in a different way and have much debate. Similar in the matter of AIDS, the Courts in the USA have ruled where the autonomy of the individual may be encroached in case they refuse to submit themselves to serious examination of AIDS. The state can compel a person to undergo examination while in Canada the law totally disagrees with it. Similarly in the matter of brain death, or genetic patentability, there are differences. Abortion in Eastern societies, India, Thailand, Korea, they are all different. Bioethics is not a philosophy which can be geographically or politically linked to one domain, it is reflection of how individuals feel and how they think. The individuals in the same country and same political regime differ. If we take this perspective we may develop a common perspective, rather than dividing the world into East and West. That is my perspective.
Macer: Thank you for the discussion and the paper, and we move onto the final paper by Prof. Pinto. Thank you, we can have one question.
Kishore: What is the Portuguese perception with regard to anencephalic children, do you feel that they can be subjected to organ retrieval?
Pinto: Transplantation is considered by a committee which has been set up several months ago. They have not asked for geneticistsf opinion yet and I do not believe that the law has been submitted to the Parliament.
Macer: Thanks to all the speakers, we have now exceeded our time so we must stop.
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