Developing bioethics in developing countries.
Bioethics (Social aspects)
Bioethics (Laws, regulations and rules)
Stem cell research (Ethical aspects)
Stem cell research (Laws, regulations and rules)
Raja, Asad J.
|Publication:||Name: Journal of Health Population and Nutrition Publisher: International Centre for Diarrhoeal Disease Research Bangladesh Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2001 International Centre for Diarrhoeal Disease Research Bangladesh ISSN: 1606-0997|
|Issue:||Date: March, 2001 Source Volume: 19 Source Issue: 1|
|Topic:||Event Code: 290 Public affairs; 930 Government regulation; 940 Government regulation (cont); 980 Legal issues & crime Advertising Code: 91 Ethics; 94 Legal/Government Regulation Computer Subject: Government regulation|
|Geographic:||Geographic Scope: Pakistan; Switzerland Geographic Code: 9PAKI Pakistan; 4EXSI Switzerland|
Bioethics, the investigation of ethical issues in medicine,
biology, and health sciences, is in vogue in the developed world.
Television news often shows feature stories on debates over the proper
uses of such new developments as embryonic stem cells or gene therapy,
and newspapers elicit public comments on their Internet sites. Societal
responses to these technological advances are mediated through bioethics
agencies within governments, working alongside numerous scholars and
interested non-government organizations. National bioethics commissions
in over forty countries offer reports and opinions to the public,
influential legislators, and public officials. Laws and regulations are
widely debated and influence the direction of science and healthcare
The role of bioethics in most developing countries is quite different. The survey of the bioethics literature in Hyder and Nadeem's paper "Health Ethics in Pakistan" shows that the potential contribution of bioethics in that country to public contemplation of ethical issues in healthcare is only beginning to be realized. The lack of a well-developed capacity for debate and reflection in bioethics in a country like Pakistan is lamentable for those who believe that bioethics might offer hope to the country in meeting its challenges in healthcare.
As Hyder and Nadeem suggest, the paramount issue in Pakistan, as in most countries afflicted with widespread poverty, is the country's severe lack of resources for public health and healthcare. This, however, does not mean that bioethics is a luxury, a preoccupation of wealthier countries that will have to wait until Pakistan achieves further development. Underdevelopment rather sets a distinctive bioethics agendum, on which the ethics of resource allocation-of who will live and who will die, of whose suffering has the highest priority when not all can be helped-is of primary importance. Priorities for bioethics will reflect those of the health system, with more emphasis on prevention than on treatment and on common and communicable diseases rather than treatment of rare and chronic illnesses. Alongside the need for resources, and for just and accountable choices within these resource constraints, there is a need for a regulatory environment for the practice of medicine and for the pharmaceutical and biotechnology industries in which the public interest remains paramount. There is also a need to reinforce awareness of the rights of patients in the public and the health professions alike. The ethical issues at stake range from the largest questions of health system reform to the individual doctor's re-use of a disposable syringe.
The relative scarcity of published reflection in bioethics in a country, such as Pakistan, represents an opportunity, for the door is open to innovation and to development of bioethics as a field of scholarship and activity that is responsive to the distinctive conditions prevailing in the country. There is no need to carry over models from developed countries, duplicating their preoccupation with the latest products of science and technology. Bioethics in Pakistan and other developing countries can make a contribution that extends far beyond national boundaries if the field engages the everyday realities that make the delivery of humane and effective healthcare such a challenge.
A comparison of bioethics in a developing country, such as Pakistan, with that of richer countries requires an account of the latter that recognizes its diversity of purpose and method. Bioethics in the West is partly a field of academic study, located in schools of medicine, the social sciences, and philosophy; but this has worked alongside a reform movement outside the academy aimed at enhancing the well-being and self-determination of the individual patient and research subject. Bioethics drew strength both from its scholarly contributors and from the commitment and energy of the social movement that sought to rectify what it took to be a disregard of the patient by an unresponsive medical profession. In time, the ideals of this movement were accepted by many health professionals and reinforced by government study commissions and regulations. The focus of bioethics was not always on high technology. It began with everyday concerns, such as the patient's consent, the need to treat research subjects fairly, and for humane treatment of the dying (2).
The agendum for bioethics in developing countries is yet to be written. Pakistan and other developing countries can make their contribution to this field by developing curricula in bioethics in schools for the health professions. This requires curriculum time and also professional recognition of the value of this teaching, using texts specifically created for use in developing countries, such as the Training Manual on Ethical and Human Rights Standards for Healthcare Professionals of the Commonwealth Medical Association (3). Publication of papers and records of debates over ethical issues in medical journals and in specialized bioethics journals, as Hyder and Nadeem suggest, can help build a critical mass of participants engaged in active national debate. Governments can create national bioethics commissions to which they can turn for advice on issues of both scientific and moral complexity. To have an impact on the experience of illness and the conduct of medicine, the development of bioethics must be accompanied with public accountability for health professionals and institutions, in the form of both self-regulation and government oversight.
Developing countries need not take these steps alone. Hyder and Nadeem write about the Global Forum on Bioethics in Research, which was created specifically to elicit developing-country perspectives. Professional groups, such as the International Association of Bioethics, which holds world congresses biannually, welcome developing-country participation. The Global Summit of National Bioethics Commissions, with its secretariat at the World Health Organization, serves to connect these national advisory bodies and might in time offer support to those in developing countries. All three of these organizations will meet in Brazil in November 2002, and periodically thereafter. Participation in these and other international for a permit mutual enrichment between bioethics in a developing country, such as Pakistan, and its counterparts around the globe.
The relation of bioethics in developed and developing countries involves information and education in both directions. In the bitter debates occurring in the West over the ethics of research in developing countries involving human subjects, it is widely agreed that in the end, the ethical decisions must be made by the host populations and their representatives rather than by bioethicists in the sponsoring countries. The development of bioethics in developing countries, such as Pakistan, is important to richer countries that sponsor research just as it is to Pakistanis.
The development of an articulate literature in bioethics in developing countries is itself a sign of strength. Bioethics requires freedom of expression, and in calling the powerful to account, in asking for justification for actions and policies, bioethics offers the hope of accountability. Bioethicists in developing countries should expect both assistance and a respectful hearing from richer countries and for international agencies, such as the World Health Organization and UNESCO, and have much to offer to one another. Bioethics, which is fortunately not an expensive endeavour, is an increasingly significant element in the process of national development.
The opinions expressed in this editorial are those of the authors as individuals, and do not necessarily reflect the policies or positions of their employing institutions.
(1.) Bulger RE, Bobby EM, Fineberg HV, editors. Society's choices: social and ethical decision-making in biomedicine. Washington, D.C.: National Academy Press, 1995. (http://www.nap.edu/books/0309051320/ html/index.html).
(2.) Rothman R. Strangers at the bedside: a history of how law and bioethics transformed medical decision making. New York: Basic Books, 1991. 303 p.
(3.) Commonwealth Medical Association. Training manual on ethical and human rights standards for healthcare professionals. London: British Medical Association, 1999. (http://www.cma.co.za/ethics/ toc.html).
Asad J. Raja  and Daniel Wikler 
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