pp. 165-169 in Bioethics for the People by the People, Darryl R. J. Macer, Ph.D., Eubios Ethics Institute 1994.

Copyright 1994, Darryl R. J. Macer. All commercial rights reserved. This publication may be reproduced for limited educational or academic use, however please enquire with Eubios Ethics Institute.

Bioethical reasoning of students in Singapore and Hong Kong

Darryl Macer,
Institute of Biological Sciences, University of Tsukuba, Ibaraki 305, JAPAN
Chin Choon Ong,
Dept. of Chemical Process Technology, Singapore Polytechnic, 500 Dover Rd, SINGAPORE 0513
Tit Meng Lim &
Dept. of Zoology, National University of Singapore, 10 Kent Ridge Rd, Singapore 0511
Maureen V. Boost
Dept. of Health Sciences, Hong Kong Polytechnic, Hung Hom, Kowloon, HONG KONG

1. Country Background

The vibrant economies of Singapore and Hong Kong have made these two small densely populated regions symbols of economic success. Singapore is has a more mixed population of the two, though 95% of the sample were Asian, including mainly those of Chinese origin. Hong Kong is basically Chinese in population, and the sample was 99% Asian. It is soon to rejoin mainland China. Both Singapore and Hong Kong have high living standards, in 1992 the GNP per capita of Hong Kong exceeded that of the U.K. Because of the similar ages and possible ethnic similarities we grouped these two samples together.

Another similarity between these localities is that many tourists visit them. In 1992 over 6 million tourists visited Singapore, the same number visit Hong Kong, and because of their small size and good communication, any new information is passed on rapidly. Both also have positive policies in promotion of science and technology. Variables that may be of particular interest are the largely urban nature of these populations, and whether this affects their views of nature; and whether living in a densely populated area affects social attitudes.

2. Sample characteristics

The International Bioethics Survey was conducted among student populations of three institutions: Second (N=60) and third (N=169) year students, majoring in chemical process technology (N=84) and biotechnology (N=145) in Singapore Polytechnic (N=229, response rate 98%); third year zoology students in the National University of Singapore (N=21, response rate 49%); first and second year medical technology students (including some optometry and radiography students) in Hong Kong Polytechnic (N=104, response rate 52%). There was a low response rate in the later two samples, and one reason is that they could be sick of receiving survey forms and reluctant to answer. It does suggest that knowledge of the questionnaire contents was not a significant factor in response. The sample size from the National University of Singapore sample is too small to make any significant comparisons between these students and the other two institutions, so they were grouped with the Singapore Polytechnic students.

A large proportion of the Singapore polytechnic students were females, in part because males tend to opt for engineering courses. Almost nobody in the samples was married, and they were all young. The oldest in the samples was 24 years old, and they were studying for their first degree. A few in Hong Kong were studying for postgraduate diplomas.

There was much more religious diversity in Singapore, and the colonial influence upon religion in Hong Kong could be clearly seen with 40% Christian, and no one saying they were Buddhist. This may also be related to the generally better English teaching at Christian schools, and the selection resulting from university entrance English exams. In Singapore 24% said they were Christian, and it is also becoming common there. Very few (3-5%) of either sample said religion was not important at all, and there was a significant trend in both of these samples to rate religion importantly compared to Australasian or Japanese students. In both regions there is religious freedom. In Singapore the predominant backgrounds were Buddhism and Taoism, consistent with the traditional Chinese religions.

3. Knowledge of science and attitudes to it

The science students were all very interested in science as expected (Q1a), and believed that most problems could be solved by applying technology (Q1b). But Singaporean students were less optimistic about the impact of science (Q4) than Australasians, or Chinese (Zhang, 1991; Macer, 1992; Lo et al. 1994). They shared similar results to the Japanese students. This pessimism was also marked in the specific technology of nuclear power (Q6). Among the Hong Kong students, there may have been more concern because of the recent opening of a nuclear power reactor in Daya Bay close to the border, amid safety standard concerns. However, in the specific examples of other technologies they were among the most optimistic sample, especially with regard to genetic engineering and biotechnology.

In vitro fertilisation (IVF) is reasonably familiar to Singapore students despite 10% saying that they had not heard of it (Q5). During a 16 week industrial training program some of them were attached to hospitals which are active in research in IVF. IVF is well accepted in Singapore due to the recent decline in birth rates. 43% in Singapore supported the use of a surrogate mother, and 36% in Hong Kong (Q1h). In Hong Kong there are two hospitals and a couple of private clinics offering IVF. Recently a sex selection clinic opened, stating that they would only aim to balance male-female ratios in families. Computers were also very familiar to these students, as they are basic courses for these university students; as was biotechnology considering the student major. However, gene therapy was not so familiar, with 25% saying that they had not heard of it, despite their very positive support for it, as discussed later.

Singaporean students were very positive about patenting (Q30), with many agreeing with the patenting of genetic material from plants, animals (55%) or humans (47%), and the patenting of an AIDS cure (73%); significantly more so than students in Australasia or Japan. They were also more positive for patenting of plants and animals, but less positive about copyright of books or inventions in general. Singapore is a country with no natural resources and the potential of biotechnology as an industry to produce value-added products is therefore exploited by the policy makers. Students are hence supportive of patenting as it implies money making.

It is interesting that several investors in Hong Kong have set up biotechnology laboratories in neighbouring China, because of not only reduced cost of land and labour, but also the less restrictive patent and copyright laws. Also in Hong Kong there is widespread illegal photocopying of books, or computer programmes, and students often use photocopies versions of textbooks rather than buying them.

4. Environmental concerns

There was strong agreement with the statements supporting animal rights (Q1i), and that the environment has a valuable property (Q1c). In Singapore there have been campaigns like "Save the Earth" and "Greenweek" to promote environmental concern, and students are encouraged to promote conservation of the earth. Projects related to the recycling of plastics and cans, etc., are given to final year students to complete. Recycling bins are placed in strategic areas, such as around the library. Advertisements related to conservation are also common in the local newspapers and on television. 51% said they had stopped buying products which cause environmental problems (Q2b), which was less than Australasia but more than Japan.

Shops which sell natural products are also doing well. Most of the food, especially vegetables, are imported fresh from Malaysia to Singapore, and from mainland China to Hong Kong, as well as from a variety of other countries. The food purchasing for these young student samples is mainly by their parents as they are living at home, so they may not be aware whether they are pesticide free or not, even if they are available in vegetable markets.

In Hong Kong there have also been several campaigns and their are active Friends of the Earth and other green groups. Recycling is still in early stages, with collection of cans by the underprivileged for economic reasons. Paper recylcing is quickly growing, but there is little recycling of glass and plastic bags. There are some environmentally friendly products available but not in big supermarket chains, and there are few or no non-phosphate containing detergents. A shop, Body Shop, which markets products with no animal testing, is popular among young people. There are regular episodes of pesticide contamination of vegetables imported from China. The public are aware but there is little alternative supply and control is difficult. There is no mention of pesticide-free vegetables in markets, and products from a company which markets organic products are expensive.

The comments given for the open questions about "life" and "nature" were generally of similar diversity and distribution to those of other countries, as can be seen in the list of comments in the appendix. A reasonably high proportion draw pictures for their response.

5. Biotechnology: non-human

79% in Singapore thought that gene transfer from plant to plant was acceptable, while 25% thought so for animal to plant. This drop was significantly greater than in Australasian students. The acceptance of animal to animal gene transfer was 41%, the same as in Australasia. Most felt that animals and plants are distinct entities and we should respect this difference, something also seen in Japanese students, and in the United States. There was low acceptance (14%) of human-animal gene transfer. However, there was positive support for the specific cases of genetically modified organisms (Q31).

93% were aware that genetically modified organisms are being used to produce food, and among the different countries the Singapore students had a higher degree of concern. They were most concerned about meat, as for other countries, and least concerned about medicines or vegetables. About 60% of these students did not write comments to this question, but very few said that they considered them "unnatural", rather they expressed"safety" concerns.

To reduce medical expenses of an aging population, Singaporeans are being encouraged to live a healthy lifestyle. The steps taken include annual exercise workouts, requests for school canteens to reduce oil in foods, or sugar in drinks, for example. Elderly couples can join in the activities organised by their local housing estate Resident's Committee. Among the students, 56% said that they had stopped eating a certain food because of safety concerns, and this is likely to increase in the future. In Hong Kong there is much publicity about healthy eating but less organisation. Many of the elderly still practice Tai-Chi. There is growing concern about obesity in the young, and the busiest McDonalds hamburger shop in the world is in Hong Kong.

Both samples expressed a high degree of trust in governmental agencies when making statements about the safety of biotechnology products (Q29). This represents a significantly more positive view towards the government than in the other countries. They were, however, equally suspicious of companies. They also expressed reasonable trust in environmental groups, university professors and doctors.

6. Genetic diseases and AIDS

There was very high support for the provision of prenatal genetic screening under government funding (Q16) in both samples (85% agreeing), with there being somewhat less support for personal use (Q17) among Hong Kong students (77%) than Singapore students (83%), though they were in greater agreement with the abortion of a fetus with congenital abnormalities (Q1g). In Hong Kong there is a wide government health care system with hospitals and clinics available to all at very low cost. Large organisations use medical insurance schemes to enable some employees to use private hospitals. In both countries there is a strong sense of health care prevails. All working Singaporeans contribute a small percentage of their wages to a special account called Medisave, from which they can withdraw for later medical expenses. In Hong Kong abortions are easily obtained, and used as a late fore of contraception. late abortions are done over the border.

A high proportion of students in Hong Kong (12.6%) gave eugenic reasons for personal support of prenatal genetic screening. This is consistent with a recent case were people objected to the establishment of a community home for person's with Down's syndrome near their houses. This will be an interesting trend to follow, especially given the recent eugenic law proposal in China to decrease genetic disease. The recent publicity about hemophiliacs who contracted HIV via AIDS may have generated more awareness, and sympathy. A high proportion of Hong Kong students listed colour blindness as an example of a genetic disease that someone they knew had. This is because all the students are screened for colour blindness before entering the medical laboratory course, because they are unlikely to get a job as a technician if they are colour blind. Other students included optometry students, who would also be familiar with this disease. In both samples thalassemia and Down's syndrome were the most common diseases that people cited. Less knew someone with a mental disease than with a genetic disease in Hong Kong.

Very few Singaporean students said they knew someone with a genetic disease, which suggests that it may be hidden. However, there was less feeling among both these samples that genetic privacy should be protected (Q21), and more than half in both samples said that an insurer deserves to know that information, unlike Australasia or Japan. They also supported the sharing of information with other members of the family more than in Australasia or the United States, like other Asian countries. In Hong Kong more people said that they knew someone with a genetic disease (43% compared to 16% in Singapore), but relatively few people reported knowing someone with a mental disease. Mental disease is more 'shameful' than genetic disease, which could account for the low reporting in both these countries. In Hong Kong there has been much objection to the siting of half-way homes for recovering mental patients in housing areas, and to centres for autistic persons.

These same trends were also seen in the privacy of HIV status. There have been cases of people losing jobs because of positive HIV status in Singapore, but 48% still thought that the employer should know. In Q22, the attitudes to people with HIV or AIDS, there is a clear result - people with HIV in Singapore or Hong Kong have a bad social position, being likely to be rejected, with high proportions saying that it is the person's own fault to get AIDS. This may represent the attitudes generated by local AIDS campaigns, and it suggests that more tolerance is desirable. In Hong Kong the government films have focused on promiscuity as the major cause, and on prostitution and "business trips" as the major dangers. Initial reactions were that AIDS was a foreigners disease, and Chinese did not get it. It is more striking because the comments given about people with the other diseases were similar to the other countries. It may be that the crowded environment of these countries makes people paranoid if someone around them is infected with such a disease. In order to "protect" themselves they would rather such questions be made open.

7. Gene therapy

Both samples had very positive views of gene therapy, with 83% in Singapore and 78% in Hong Kong being willing to undergo gene therapy on themselves (Q26), and 91% and 85%, respectively, willing for their children to undergo it (Q27). The reasoning expressed was similar to other countries. They did distinguish therapeutic and enhancement uses (Q28).

8. Conclusion

Due to good infrastructure and educational programmes, Singaporeans generally have strong faith in research and development. They therefore are also hopeful in matters, especially gene therapy. The positive view seen in this survey may also be due to the fact that the samples surveyed are students who trained in technology, especially biotechnology. Singaporeans also tend to have strong faith in governmental agencies because they have been under the same government for more than 25 years, during which time the living standard has been improving.

Periodic surveys of the opinions of people living in these two small countries are important because the results can show significant differences and trends. This could be due to their close proximity to large neighbouring countries which can have different policies and religions, and are of special interest for Chinese studies, as discussed in the overview of the survey results. In the case of Singapore, the three neighbouring countries are predominantly Islamic countries while in Hong Kong, it reverts back to China after 1997 from the current British rule. One of the other problems in bioethics in Hong Kong is the travelling of persons to China to receive organ transplants, including organs from executed prisoners. Hong Kong people are worried about human rights in China and this leads to worries over ethical issues.

There survey data suggests there is a positive view of technology, also found in India and Thailand, like China (Lo et al., 1994), but that Singapore and Hong Kong students have more limits over how far they will apply science for enhancement uses like the other countries in this survey, Japan, Australasia, The Philippines, Israel and Russia.

9. References

Lo, W.H.Y. et al., "A survey of people with higher education to genetics and diseases in Beijing", pp. 195-198 in N. Fujiki & D.R.J. Macer, eds., Intractable Neurological Disorders, Human Genome Research and Society (Christchurch, N.Z.: Eubios Ethics Institute 1994). Macer, D.R.J. (1992a). Attitudes to Genetic Engineering: Japanese and International Comparisons. Christchurch: Eubios Ethics Institute. Zhang, Z. (1991) "People and science: Public attitudes in China toward science and technology", Science and Public Policy 18: 311-7.
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