Bioethics in and from Asia

Journal: Journal of Medical Ethics 25 (1999): 293-295.
Author: Darryl R. J. Macer
The majority of the world's population live in Asia, the popular international religions of the world originated in Asia, and the world's largest English-speaking country (India) is in Asia. Considering this, we may ask why there have hitherto been so few papers from Asia published in the Journal of Medical Ethics (or most other journals dealing with medical or environmental ethics)? While the economic centre of the world has been shifting to Asia, and most people are using products made from Asian-based companies, few papers in bioethics have been written from Asia. In this editorial I want to discuss whether there is any Asian bioethic, and where readers can find the "missing" papers on Asian bioethics.

In this issue of the Journal we see a welcome mini-symposium of no less than five papers from East Asia. Akabayashi et al.[1] discuss two central issues in cross-cultural ethics, namely, whether respect for individual autonomy and informed consent should be universal, and who should be told the truth about medical diagnoses first? The issues are faced in not only Japan or Asia, but in most traditional societies. The common response to "paternalism" is against dominant health care professionals who despite a general public desire to know the truth, think it is not in a patient's best interest to be told or else do not feel competent to explain and counsel the patient.

Some health care professionals may also consider that the family knows the patient better than they, and share the responsibility of consultation with family members, so-called "familial autonomy". There are some families in all societies who function as one, and other families which function as relationships between individuals. It may be difficult to know which type of family each one is. In the case discussed by Akabayashi et al., the family had explained that while still healthy the patient had mentioned to them her wish not to be told if she developed cancer. Therefore the physician used "familial consent". However, as they also cite there are numerous public opinion surveys in Japan since the 1960s suggesting a clear majority of individuals wish to be told.

Actually in Japan we also see a long tradition of controlling our own death, whether it be the practice of lover's suicide (shinjuu), or the tale of the 46 samurai who killed themselves after enacting revenge for their leader's murder, in 1703. However, the most learned and respected samurai do not use artificial means to cause death. They use natural death, as seen in the case of Yamaoka Tesshu, the most influential swordsman of the 19th century Japan. He was a Zen samurai who predicted the time of his own death, and controlled his own respiration naturally to die. This could be the ultimate in informed choice of death! We could see the living will as a natural extension of Japanese tradition, and a long awaited return of the samurai tradition which was discouraged since the Second World War. I do not, however, mean that we should live in a land of Zen samurai, but rather that we can find the tradition of informed choice in the long history of Japan. The survey of physicians conducted by Asai et al. in Japan over PVS provides more data on patient care. [2] We need to really have in depth cross-cultural dialogue and study rather than defining one ethics as Asian and one as not. The interesting point for cross-cultural ethics is at what point do you call something distinctly "Japanese" or "Asian" or "British". The answer to this may depend upon what literature and practices we are familiar with.

People may be unwilling to take decisions alone, or even as a family, when it comes to health matters. The Chinese study by Liu et al. suggests the DNR orders are seldom signed by patients themselves. [3] The study by Tsai in this issue shows that ancient Chinese medical ethics may follow a four principles approach, but with more emphasis on beneficence than autonomy. [4] Some persons or families may be too dependent upon the physician, [5] which is the other side of the barrier to informed consent. A contrasting paradox in Asian medical ethics is the question of trust. In the International Bioethics Survey conducted in 1993 in ten countries across Asia and the Pacific, Japan was found to be the least trusting of statements by doctors. [6] Arguably, the lack of trust has been a barrier in the implementation of some techniques, such as organ transplants. [7] One of the reasons for a lack of trust is the lack of truth-telling and openness.

No mention of Asian bioethics would be complete without discussing use of brain dead organ donors. Despite the practice of transplants and questions of consent and commerce in Chinese, Indian and Philippine practice, Japan only accepted the option of organ transplants from brain dead donors in 1997, and South Korea is expected to accept it legally by the year 2000. In Japan, people have an option on how to define death [8]. In March, 1999 the first heart transplant from a brain dead donor was conducted in Japan, 31 years after the only other operation in 1968. The donor carried a donor card and family agreed with her wishes. The media spectacle made many aware of the transplant, but also invaded the privacy of the family of the deceased. The hospital announced brain death before they finished confirming the diagnosis of clinical brain death, so the media waited for 2 days outside the hospital. The heart went to the correctly assigned recipient, after doctors checked the system and found the person second in the list had been mistakenly told they were first! Such mistakes on national media displayed the system of checks, but also how mistakes may occur. The long public debate has made most people in Japan aware of the terms at least, and more Japanese would no what is brain death than people in most other countries who immediately accepted the medical view.

The media is clearly a major factor in influencing bioethical decisions in all countries. The discussion of bioethics can transform the whole style of society. [9] This spirit of openness is one of the reasons why the Eubios Journal of Asian and International Bioethics (EJAIB) is on-line <">. EJAIB publishes about 70-80 papers a year, and is the official journal of the Asian Bioethics Association. When we start to explore, there are actually a growing number of publications by authors in or about Asia, and conference proceedings on-line include around 500 papers, and we could say that the "Far East of Bioethics" [7] is no longer inaccessible for those who wish access, though there is much more descriptive work required.

The first week of November, 1998 saw the Fourth World Congress of Bioethics (IAB4) and Fourth International Tsukuba Bioethics Roundtable (TRT4), held in Japan. [10] Scholars from about 50 countries joined in dialogue on cross-cultural issues. There were a variety of approaches. The approach I most favour for future study is exploring the question of whether "Bioethics is love of life". [11] From the past years of research across many countries I think "love" can be a fruitful language for debate in bioethics, despite its ambiguity. We can consider the four principles of love bioethics, as self-love (autonomy), love of others (justice), loving life (non-maleficence) and loving good (beneficence). I argue that love is not only a universally recognised goal of ethical action, but is also the foundation of normative principles of ethics. At TRT4 we saw people from all continents agree with the concept of love as a universal value, and persons from Australia, Cameroon, Japan, Nepal, India, Russia, USA, China, Iran, Philippines and Thailand gave examples of how the concept of love was expressed in both ancient and modern bioethics. [12] It was enlightening to add to the numerous quotations on the subject, but it needs further clarification beyond the style of situation ethics. [13]

There are other key words that emerge from Asia, such as harmony and tolerance, respect and reverence, and ambiguity. There is diversity within every society over the bioethics that each person has, and the relationships that shape the balancing of principles or ideals. While Asia has a rich tradition in views of life, there is still a gap between the real world and the ideal. Few of the ideals of respecting life are actually applied to everyday applications, and to deciding how to use medical technology. However, this may not be so different from the real world of the clinic in most societies. Comparative ethics needs to break from ethnic or cultural generalizations and start to critically examine words, motives and action.


1 Akabayashi A, Fetters MD, Elwyn TS. Family consent, communication, and advance directives for cancer disclosure: A Japanese case and discussion. Journal of Medical Ethics 1999; 25(3), THIS ISSUE.

2 Asai A. et al. Survey of Japanese physicians' attitudes towards the care of adult patients in persistent vegetative state. Journal of Medical Ethics 1999; 25(3), THIS ISSUE.

3 Tsai DF-C. Ancient Chinese medical ethics and the four principles of biomedical ethics. Journal of Medical Ethics 1999; 25(3), THIS ISSUE.

4 Liu JM. The status of the do-not-resuscitate order in Chinese clinical trial patients in a cancer center. Journal of Medical Ethics 1999; 25(3), THIS ISSUE.

5 Asai A. Barriers to Informed Consent in Japan. Eubios Journal of Asian and International Bioethics 1996; 6:91-3.

6 Macer DRJ. Bioethics for the People by the People. Christchurch, N.Z.: Eubios Ethics Institute, 1994.

7 Macer DRJ. The 'far east' of biological ethics. Nature 1992; 359: 770.

8 McConnell JR. The ambiguity about death in Japan: an ethical implication for organ procurement. Journal of Medical Ethics 1999; 25(3), THIS ISSUE.

9 Macer DRJ. Bioethics may transform public policy in Japan. Politics and Life Sciences 1994; 13: 89-90.

10 IAB4 and TRT4 abstracts are on-line <>

11 Macer DRJ. Bioethics is Love of Life. Christchurch, N.Z.: Eubios Ethics Institute, 1998.

12 Macer DRJ et al. Papers from the TRT4 Symposium, Is Bioethics Love of Life? Eubios Journal of Asian and International Bioethics 1999; 9: 33-49.

13 Fletcher Joseph. Situation Ethics: The New Morality (SCM Press, London, 1966).

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