Bioethics in Asia


pp. 277-80 in Encyclopedia of the Human Genome (Nature MacMillan, 2003).
Author: Darryl R. J. Macer

Institute of Biological Sciences, University of Tsukuba,
Tsukuba Science City 305-8572, Japan
Fax: Int+81-298-53-6614
Email: Macer@sakura.cc.tsukuba.ac.jp
Director, Eubios Ethics Institute <http://eubios.info/index.html>


The discussion of the ethical, social and legal aspects of human relationships with life have a long history of discussion in Asia. While the general principles to resolve bioethics dilemmas in Asia may be similar to global ones, there have been some different emphasizes, especially in the policy making for environmental and medical ethics.


1. Introduction
Despite the economic growth, and scientific and technological progress there is little work on the ethical impact of science in Asia. Public discussion of bioethics has only begun in the last few years. The delay is more related to the structure of Asian society than to any difference between individual person's attitudes in Asian and Western countries.
Fundamental to the discussion of the topic of bioethics in Asia is the definition of bioethics. Is there any Asian bioethic, or Chinese bioethic, as distinct to a Western bioethic or African bioethic? Let us consider some issues in cross-cultural ethics in order to illustrate possible answers to these questions.

2. Are bioethics principles universal?
Bioethical decision-making involves recognition of the autonomy of all individuals to make free and informed decisions providing that they do not prevent others from making such decisions. This is consistent with democratic principles, and the extent to which a society has accepted this is one criteria of the success of bioethics. However, the structured paternalism of East Asian societies is built on the idea that only the views of so-called experts (sensei) should be heard. It also means that their views should not be questioned, in accordance with the traditional paternalistic Confucian, or pseudo-Confucian, ethos. Medicine is "an art of Jin", the expression of loving kindness (Jin) by the health care professional. The main theme of Confucianist ethics was the maintenance of moral discipline for the nation, society and the home; and it was to the benefit of rulers and family leaders. Therefore, it is not surprising that many of the authorities in Asian society share this ideal because it means respect for them, and hence reject autonomy-centred bioethics. They may promulgate the idea that Chinese or Japanese are different as an attempt to prolong the Confucian ethic.
However if we look into other parts of the ancient culture we can see basic bioethical principles of autonomy and justice, non-maleficence and beneficence are seen. Tsai (1999) shows that ancient Chinese medical ethics may follow a four principles approach, but with more emphasis on beneficence than autonomy. Macer (1998) considers that bioethics is love of life, not only in Asia, and also uses four principles, being self-love (autonomy), love of others (justice), loving life (non-maleficence) and loving good (beneficence).
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 that people like to talk about. 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.
To do this we need to think of what we mean as "bioethics". There are three ways.
a. Descriptive bioethics. The way people view life, their moral interactions and responsibilities with living organisms in their life. One of the tendencies of bioethics has been for people to prescribe what is right and wrong, of course in their own of view. If we are trying to reach a truly global and universal description of the way people reason and evaluate moral dilemmas we have to ask people how they think. This is especially important in cross-cultural ethics.
b. Prescriptive bioethics. To tell others what is good or bad, what principles are most important; or to say something/someone has rights, and others have duties to them.
c. Interactive bioethics. Discussion and debate between people, groups within society, and communities about descriptive and prescriptive bioethics.
When we ask whether Asian bioethics is special we can consider whether there is a special world view? In Asian style democracy public opinion is seldom influential in determining public policy and there are no effective means used by the public to change policy. The adoption of bioethics and bioethical reasoning is set to transform modern Asian culture, in greater ways than it has in North America or Europe. In most Asian countries no truly open national forum has existed for any major policy, and the establishment of such a multi-disciplinary forum represents in itself a transformation of society structure. Therefore particular issues may spark this transition, and in following sections three such issues are discussed, genetic diagnosis, organ transplants and brain death, and genetics and reproductive technology.
There are several ways to argue for environmental concern, and the emphasis in Asia may tend to be different, although all strands are found everywhere. The first is a human-centred or anthropocentric view. Biocentric focuses on biological organisms and may also make a hierarchy between different organisms. As a general principle, there is less support for making a hierarchy of organisms in Asia because all lives have souls, however humans are considered special. Ecocentric views consider the ecosystem or biosphere as a unit. While some scholars have the argue that because of polytheistic religion Eastern persons and societies are more ecocentric than Western monotheistic ones, unfortunately environmental destruction continues everywhere and there is no evidence that Eastern persons love the environment any more than their Western counterparts. The grass roots environmental movements also tend to be smaller in Asia.

3. Respect for individual autonomy and informed consent
The societal progression from paternalism to informed consent is occurring later in Asia than it did in North America and Western Europe. However there is a clear change underway (Asai, 1996; Akabayashi and Fetters, 2000). One example is truth telling, which is not only related to prognosis of cancer, but also to the issue of presymptomatic genetic diagnosis. Who should be told the truth about medical diagnoses first? The patient or the family, or no one? The issues are faced in not only Japan or Asia, but in most traditional societies. In Japan half the doctors will tell the truth about terminal cancer, however in Vietnam only one fifth will do so.
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 consider that the family knows the patient better than they, and share the responsibility of consultation with family members. In this case rather than individual autonomy we can consider this to be "familial autonomy" (Macer, 1999). There are some families in all societies who function as one, and other families that function as relationships between individuals. It may be difficult to know which type of family each one is unless a physician knows them for some time. While the trend is towards telling the truth, there are cases in Japan, and among Asian immigrants to Western countries, for example, where the family explains to the medical staff that the patient does not wish to be told if they develop cancer. However when we consider that only a half of the people utilize presymptomatic genetic diagnosis in Western countries, the desire not to know may not be unique to Asia in the 21st century. It was world-wide not to know at the start of the 20th century.

4. Organ transplantation and trust
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 (Becker, 1999), Japan only accepted the option of organ transplants from brain dead donors in 1997, and South Korea in the year 2000. 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 (Morioka, 1995).
A 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 (Macer, 1994). Arguably, the lack of trust has been a barrier in the implementation of some techniques, such as organ transplants. One of the reasons for a lack of trust is the lack of truth-telling, as discussed above, and openness in decision making.

5. Genetics and reproductive technology
When individuals in Asia are asked to give their reasoning for their opinions over bioethical issues such as genetic manipulation of humans or animals, there is as much variety in opinions expressed by members of the general public in Japan as in Australia. From the results of the International Bioethics Survey conducted in 1993 in 10 countries in the Asia Pacific Region (Australia, Hong Kong, India, Israel, Japan, New Zealand, the Philippines, Russia, Singapore, Thailand), we can see many people perceive simultaneously both benefits and risks from science and technology (Macer, 1994).
A number of questions on genetic technology were asked. The diversity of reasoning exposed in the survey was independent of education or age, and similar diversity of reasoning was found among members of the public, high school biology teachers, and scientists. The overall statistical results are similar to results of surveys in Australasia, Europe, India, Russia, Thailand and the U.S.A, although there is a recent trend to be more suspicious of biotechnology when applied to genetically modified food.
Assisted reproductive technology is being used in Asia, in countries with low birth rates like Japan, and those with high birth rates like India. There have been many children born from the use of in vitro fertilization (IVF) followed by embryo transfer. In Japan IVF is only offered to married couples in private clinics, and it is regulated by professional guidelines of the Association of Obstetrics and Gynecology rather than by legislation. The only law on reproductive technology in South or East Asia is a cloning law in Japan, in effect from June, 2001, which forbids transfer of a human embryo made by nuclear transfer into a mother. A significant difference between the attitudes of Japanese and other persons in Asia was observed in the International Bioethics Survey. There is less perception of the benefits and more anxiety about it in Japan, however there were 11,000 children born from it in the year 1999 in Japan, and over 2000 clinics. Therefore one would expect preimplantation diagnosis to expand.
There is positive support for gene therapy research in Asian countries. In China, India and Thailand, there is little concern about the impact of science and technology, and we also observe higher support for eugenic improvement of human beings in surveys in these countries (Macer, 1994). Therefore one could predict that biotechnology will expand more quickly in these countries than in Western countries like Europe, which have public reservations about the extent to which we apply these technologies to human beings. While Europeans may stop because their governments may impose policy restrictions against enhancement beyond medical therapeutic use of genetic technology, in Asia there will be less regulation, and a greater proportion of the population who supports these uses.

6. Future of bioethics
The Eubios Journal of Asian and International Bioethics (EJAIB) is on-line and is the main academic journal in Asian bioethics. EJAIB publishes about 70-80 papers a year, and is the official journal of the Asian Bioethics Association. Asia is defined for the general purposes of this journal as the geographical area, including the Far East, China, South East Asia, Oceania, the Indian subcontinent, the Islamic world and Israel. It attempts to overcome the barrier to the dissemination of information in and between persons in Asia. Few libraries have journals to encourage research, although many isolated individuals may have thought about bioethics. 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, though there is much more descriptive work required.
There are few organizations in bioethics in Asia. The Eubios Ethics Institute founded in New Zealand and Japan has attempted to develop a network of among Asian bioethics researchers since 1990. In 1989 the Japan Association of Bioethics (JAB) was founded, and in 1998 the Indian Association of Bioethics (AIBA). The Chinese Association of Medical Ethics claims two thousand members, also founded at the start of the 1990s. There have also been alternative societies founded in these countries that focus on bioethics issues, as well as bioethics associations founded in different countries including South Korea, Nepal and Pakistan.
Bioethics education will be essential for the Asian region. The International Bioethics Education Survey in Japan, Australia, New Zealand and India found that even though bioethics was not in the curriculum, a majority of teachers in each country were discussing social and ethical and environmental issues of science and technology. In Japan there is a bioethics education network for Japanese high-school teachers and with almost 100 members, founded in 1996. Despite leading the world in standards for science education, teaching on the ethical impact of science and technology is not as common as in the West.
If the future application of genetics in Asia is to be well considered, education will need to be expanded. At the same time the world has much to learn from Asia, the complexities of the situation mean that both a technophilia and technophobia can coexist. While Asian culture can appear more regulated because of paternalism, in fact, it is also more chaotic and unregulated than Western culture. The region is rapidly being changed by globalization, and in conditions such as these history would teach us that people tend to be open to more radical application of technology to life than they do otherwise.

References
Akabayashi A and Fetters MD (2000) Paying for informed consent. Journal of Medical Ethics 26: 212-4.
Asai A. (1996) Barriers to informed consent in Japan. Eubios Journal of Asian and International Bioethics 6:91-3.
Becker C (1999) Money talks, money kills - The economics of transplantation in Japan and China. Bioethics 13: 236-43.
Macer DRJ (1994) Bioethics for the People by the People. Christchurch: Eubios Ethics Institute.
Macer DRJ (1998) Bioethics is Love of Life. Christchurch: Eubios Ethics Institute.
Macer DRJ (1999) Bioethics in and from Asia. Journal of Medical Ethics 25: 293-295.
Morioka M (1995) Bioethics and Japanese Culture: Brain Death, Patients' Rights, and Cultural Factors Eubios Journal of Asian and International Bioethics 5: 87-91.
Tsai DF-C (1999) Ancient Chinese medical ethics and the four principles of biomedical ethics. Journal of Medical Ethics 25(3).

Bibliography
See on-line publications of Eubios Ethics Institute .
Azariah J, Azariah H and Macer DRJ (eds) Bioethics in India. Christchurch: Eubios Ethics Institute.
Fujiki N and Macer DRJ (eds) (1998) Bioethics in Asia. Christchurch: Eubios Ethics Institute.


Definitions
AUTONOMY: The governing of one's self according to one's own system of morals and beliefs. 1. the absence of external constraint and a positive power of self-determination often applied to the right of personal freedom in actions, choices, beliefs and preferences, bioethics = self-love 2. in political philosophy the right of self-government of community, group or state, to formulate and enforce its own laws, policies and affairs; being independently accountable 3. biological organic independence evolved and controlled by natural laws and not subject to any other [Greek autos meaning self and nomos meaning law].
BENEFICENCE: The state of doing or producing good, compare to NONMALEFICENCE. 1. in ethical theory doing and loving good, active kindness deed or work for others, bioethics = loving good 2. in science the obligation to maximize possible benefits and minimize possible harms, reflecting on social and cultural implications [Latin 'beneficum' meaning to gain prosperously as in benefit or blessing especially from God as in benediction].
BIOCENTRIC Central prime mover is a consideration of equality to all forms of life. It considers the view from the individual organism, and may ascribe equal rights to all forms of life.
BIOETHICS 1. the study of life ethics. A word coined in the later part of the 20th century to describe the various rights and wrongs of new scientific and technological procedures and discoveries (in particular in response to human experimentation during World War II) which were seen to bear a direct and significant impact upon humane survival'. 2. Rules of conduct in scientific research and involves many disciplines and skills such as law, philosophy, theology medicine, science and technological research [derived from Greek bio- life and ethicos moral]. 3. Love of Life.
ECOCENTRIC: Viewpoint giving importance to ecological processes, living in tune with nature, an accent on ecobalance, recycling, conservation of natural resources.
JUSTICE 1. fair, just conduct, self-authority in maintenance of equity, in bioethics = love of others 2. judicial proceedings, brought to justice, court of justice, magistrate, judge treating fairly personified in art as a goddess holding balanced scales or a sword with sometimes veiled eyes portraying impartiality. In 11th Century, the name Justitia was applied in a general way to persons charged with the administration of the law 3. theological quality of being morally righteous, serving the divine law and exhibition of this principle in action in the sense of 'one of the four cardinal virtues'.
NONMALEFICENCE: The state of not doing harm or evil; compare beneficence. 1.non-harmful or non-evil, bioethics= loving life 2. Medical usage non-malpractice or conduct, an obligation to not inflict pain, harm, misinformation or risk on others- avoid malevolence [Latin non not] see MALIFICENCE.

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