Medical Ethics, History of South and East Asia: V. Southeast Asian Countries
V. SOUTHEAST ASIAN COUNTRIES
Southeast Asia is part of the continent where the major faiths arose; it is still a melting pot of different religious traditions and cultural beliefs, including animism and magic. Despite the rapid social change Southeast Asia has been undergoing, these religious and cultural beliefs remain vital, conditioning people's perceptions, values, attitudes, and behaviors in health and all other areas. An understanding of these beliefs is imperative for the implementation of projects in medicine and public health, and for the maintenance and improvement of public welfare.
This article will first analyze the different types of traditional medicine in Southeast Asian countries, particularly Thailand, the Philippines, Malaysia, and Indonesia, their concepts of health and disease, methods of healing, their practitioners, and their ethics. Second, it will discuss some central biomedical issues in the practice of modern medicine, and the current efforts to teach the new medical ethics at medical schools in these countries. Finally, it will argue as a matter of great urgency the need to promote and strengthen bioethical education and research in Southeast Asia, in order to enable its medical community to cope with the new ethical and moral dilemmas, challenges to its traditional morality and religion.
Magic, Religion, and Naturalism
Medical systems in Southeast Asian countries may be classified into two types, traditional medicine and modern (scientific) medicine. Traditional medicine in turn can be very broadly grouped into three general types, depending on whether it is dominated by magic, religion, or naturalism. Beliefs concerning health, disease and its treatment, and preventive measures are in accord with the type of traditional medicine practiced. When magic is the focus, disease is believed to be caused by sorcery, and countersorcery and other spells are used as medical remedies. Similarly, when religion predominates, disease is attributed to supernatural forces, which must be appealed to or propitiated. When it is dominated by naturalism, disease is defined in terms of natural processes and the imbalance of elements or opposing forces in the body, and a judicious equilibrium is the basis of medical practice.
These traditional medical systems are often a blend of two or more types. Traditional Chinese medicine in Singapore, for example, is largely secular or naturalistic but includes magico-religious elements. Traditional Thai and Malay medicine is mainly magico-religious but is also permeated by elements of naturalistic medicine.
Healers, Shamans, and Mediums
Traditional medicine is integrated into a complex of beliefs and values comprising the worldview of Southeast Asian peoples. The magico-religious medicine of Southeast Asian countries is derived from magico-animistic beliefs that suffuse their cultures. In this cultural orientation, healers are shamans and mediums, and healing is effected through sorcery, exorcism, and spirit possession, assisted when necessary by herbal concoctions and massage.
Spirit possession is believed to be a channel by which deities or spirits of a high order (e.g., spirits of monks or saints) use their divine power to heal the sick. Healing includes a diagnosis of illness and the performance of corresponding magical rites. These magical activities are usually conducted within the religious framework of the healer. Thai Buddhist shamans, for example, do not practice on wan phra, a Buddhist Sabbath observed at the four phases of the moon, and they make use of recitations from the Pali Buddhist texts. The Malay Muslim shamans add verses from the Qur'an to their healing, while the Taoist shamans in Singapore recite Tao incantations in their practice.
Herbalists, Folk Medicine Doctors, and Monks
While the magico-religious medicine of Southeast Asia is tied to its culture, its naturalistic medicine is heir to the Indian ayurvedic medical system and traditional Chinese medicine. In these medical traditions disease is understood as a disturbance of inner equilibrium that can be corrected through the administration of herbal solutions. Thus this form of medicine is designated as naturalistic or herbal, and its practitioners are known as herbalists, ayurvedics, or folk medicine doctors. In Thailand many of these healers are Buddhist monks, who usually combine herbal treatment with religious rituals (e.g., the taking of religious vows and the sprinkling of lustral water) and meditation. Some of these monks have been credited with successful rehabilitation of drug addicts. The use of meditation differentiates traditional Thai medicine from the medicines of other Southeast Asian countries.
Medical Ethics in Traditional Medicine
The preoccupation of traditional medicine with magic, religion, and herbal concoctions is due to its holistic approach to health and healthcare. The practitioners work on their patients at both the physical level and the psychological/spiritual level. While herbal concoctions are mainly used to cure patients' physical illness, magico-religious rites have a therapeutic effect on their minds. The rites reassure patients of divine blessing and protection, and strengthen their self-confidence.
This traditional method of healing may be especially suitable today for Southeast Asians, who, living in societies with increased urbanization and industrialization, need physical, psychological, and spiritual care to enable them to cope with such change and the strains and stresses of modern life. Modern Western medicine with its advanced knowledge and technology has more effective means of healing, but it divides the patient into organ systems and treats only those parts of the person that are afflicted by a specific disease, rather than the whole person. Southeast Asians, who do not divide the person in such a way but need treatment with scientific medicine, will often seek traditional medicine as a supplement to scientific medicine. For example, a patient with a brain tumor might request magico-religious rites from a Buddhist shaman in order to ensure the success of an operation to be performed by a neurosurgeon. It was reported in the Thai press that the patient who uses this approach experiences such an operation with great calm and recovers more quickly.
Medical ethics in Southeast Asian traditional medicine is not codified but is inherent in the values and practices of its practitioners. Some of these healers are Buddhist monks whose ethic of conduct approximates the Buddhist ideal of showing compassion and loving kindness. For example, they do not charge fees and solicit no gifts for their healing. Other healers may demand fees for their service, but their code of ethics requires that they be under some self-imposed moral restraints, for example, that they not practice for monetary gain; that they serve their patients impartially, with only their benefit in mind; and that they not take cases that they cannot treat successfully. Having no common standard of practice to follow, the healers' success depends on their own virtues and healing powers. Their services are sought as long as they can instill belief and faith. They sink into anonymity when they are seen as charlatans or when doubt about their powers arises.
Modern Medicine and Healthcare Allocation
Modern medicine came to Southeast Asia during the colonial period, starting in the eighteenth century. Since then it has made tremendous progress. It has greatly benefited people in Southeast Asia, but beneath the surface of these benefits there is a multitude of attendant ethical problems.
The most important concerns the macroallocation of limited healthcare resources, specifically, grave inadequacies and inequalities in their distribution. Nearly 80 percent of the population of Southeast Asia lives in rural areas. Most of these people are poor and need more medical services than affluent people. Their health depends mostly on medical services provided by the government through hospitals and public health centers. Yet many of these services are inaccessible to them. In Thailand, for example, 62 percent of doctors and nurses are in Bangkok, where most of the country's hospitals are, while there are too few doctors and nurses in the provinces, where most of the people are. There are also too many hospitals in Bangkok and too few neighborhood clinics and public health centers in rural areas.
Southeast Asian countries, eager to bring the benefits of modern medicine to their people, have modeled patterns of healthcare and education of health personnel in their countries on those in more affluent and developed nations in the West, particularly Britain and the United States, without regard to social, economic, and cultural differences. As a result, limited healthcare resources are allocated to catastrophic or hospital-oriented medicine, despite the fact that most of the diseases afflicting the majority of people in these countries are preventable. Even though it has become increasingly clear that these patterns are irrelevant to the health needs of developing Southeast Asian countries, Western-trained health policymakers are very reluctant to deviate from these models, which are being questioned even in the developed nations where they originated.
Politically pressured to show more concern for the poor, governments in some Southeast Asian countries are now acting to correct some of the imbalance of resource allocation. The present Thai government, for example, though still following Western models, has increased funding for preventive health measures and public health services. More provincial hospitals and health clinics are being built, and paramedics and auxiliaries trained to staff them. Thai medical schools now require medical graduates to spend at least three years in the provinces and rural areas, and a plan is being devised to provide incentive subsidies to doctors and nurses working in poor rural areas. Many more corrective measures are needed to create a just and reasonable allocation of the country's overall healthcare resources such that the general standard of health and healthcare can be raised nationwide.
Shortages of health personnel in Southeast Asia have been aggravated by the fact that so many doctors and nurses are lured from their homelands, where they are in desperately short supply, to serve the less critical health needs of affluent nations. The Filipino Department of Health, for example, reported in 1990 that two hundred towns in the Philippines had no resident doctors and that seven out of ten persons died without even being seen by a physician. Only an estimated 32 percent of all qualified Filipino doctors and nurses practice their profession in their own country. This shortage of doctors and nurses, typical of developing Southeast Asian countries, makes it much more difficult for governments to provide adequate healthcare to many of their people.
Human Experimentation
Another important ethical issue in Southeast Asia concerns human experimentation. Since the adoption of modern medicine in the nineteenth century, medical schools in Southeast Asian countries have become more research oriented and are increasingly moving into the area of human experimentation. In violation of international agreements, Western researchers who have been restricted in the kind of human experiments they may do in their own countries are turning to Southeast Asia to conduct their research where there is less public awareness of the issue and less government regulation. These researchers are usually assisted by Southeast Asian colleagues, who engage in all kinds of human experimentation no longer permitted in the West, including forms of psychosurgery and genetic experiments. Drug testing and tests of new contraceptives have been carried out in Southeast Asian countries on a massive scale. Nearly all of these experiments use poor people as subjects, without their informed consent. Abuse of poor patients and the violation of their human rights in public hospitals often occur.
The governments and the medical communities in Thailand and the Philippines have taken some measures to prevent the exploitation of the poor by researchers. In 1985 the National Research Council of Thailand formulated guidelines for research involving human subjects; these guidelines were later revised and made more elaborate. In 1987 the Philippine Council for Health Research and Development published National Guidelines for Biomedical Research Involving Human Subjects, similar to those delineated by the World Medical Association at Helsinki in 1964 and revised at Tokyo in 1975. These guidelines on human experimentation laid special emphasis on voluntary informed consent of research subjects. Unfortunately, both in Thailand and in the Philippines there is as yet little compliance with these guidelines or accountability for their violation.
The creation of national ethics committees and institutional review committees in Thailand and the Philippines is another Southeast Asian response to the issue of human experimentation. These institutional committees are concerned primarily with the evaluation of the scientific value of research proposals; the national ethics committees are expected to deal with the ethical aspects of experiment proposals and their protocols. Both the proper role and the composition of national ethics committees are still being debated. At present such committees are far from being instruments for effective control of experimentation in Southeast Asian countries. The Thai committee, for example, does not scrupulously supervise procedures for gaining the needed informed consent. Nor does the committee intervene when it believes an experiment is being conducted without proper ethical consideration. A 1988 study in Thailand indicated that often the procedures followed in many hospitals made it unlikely that the patients were fully informed or gave genuinely voluntary consent. Though many questions are being raised about it, this national committee could become an effective means to prevent morally questionable experiments on human subjects from being performed.
Traditional Morality and New Ethical Issues
The traditional morality of Southeast Asia is permeated by the ethical traditions of Hinduism, Buddhism, Christianity, and Islam. The emergence of modern medicine has produced many new ethical issues that challenge traditional morality. For example, within this morality is the cardinal Buddhist principle of adhimsa, which directs that life not be taken and harm not be done. Modern medicine with its advanced technologies has produced ethical dilemmas concerning how to abide by these precepts. For example, does removal of a life-support system constitute violation of these precepts? Is allowing a seriously defective infant to die untreated a form of harming or killing? Is it morally acceptable for patients to take their own lives in cases of lingering terminal illness or chronic severe pain or disability? Is it morally acceptable that doctors or nurses act upon the expressed desire of patients and assist them in committing suicide when they are unable to act for themselves or to find the means to do so? Is removal of a kidney from a live donor a morally justified form of harming?
Traditional morality also dictates that we not deceive others. One of the five precepts of Buddhist morality prohibits falsehood. Does this include failing to tell a terminally ill patient the truth about his or her prognosis? Is administering placebos a morally justified exception to the moral rule against deception? Can the patient be deceived about a treatment if the doctor or nurse thinks it is in the patient's best interest? Must all the truth about a double-blind trial in human research be told in order to obtain the informed consent that the new medical ethics calls for? These are examples of new questions raised as a result of the encounter between modern medicine and traditional morality in Southeast Asia. Traditional morality is no more prepared to deal with these new moral issues than are the Southeast Asian scientists and physicians caught in the middle of them.
The development of modern medicine has raised questions about the adequacy of traditional morality. For example, the traditional Buddhist concept of death as the cessation of all vital functions cannot accommodate the recent development in modern medicine, in which some cells or organs may be sustained by artificial means after the cessation of all vital functions. Nor does it facilitate early retrieval of organs for transplantation. Southeast Asians must rethink and reinterpret the applications of their traditional morality to cope with the advanced knowledge and technologies of modern medicine. For example, as technologies for behavior control and modification are available through drugs, electrostimulation, electroshock treatments, psychological manipulation, psychosurgery, and genetic engineering, the traditional precept of "do no harm" to an existent being may be stretched to cover the question of whether we have the right to create a being of our own design.
Teaching and Other Bioethical Activities
Southeast Asian medical students usually learn about medical ethics in classes, and from time to time through lectures outside of regular classes. They are also encouraged to follow the example of morally respected elder doctors. In the past the teaching of medical ethics at medical schools in Southeast Asian countries was integrated into other courses and was primarily concerned with professional etiquette as developed in the West or culled from the teachings of Buddhism, Hinduism, or Islam.
The new medical ethics, or bioethics, was initiated in Southeast Asian countries as a response of scholars and medical professionals to the impact of modern medicine on the life and well-being of people in their countries. Through the combined efforts of Christian clergy and doctors, the Center for Biomedical Ethics Development was established in Indonesia in 1983, primarily to enhance the development of bioethics and Christian values in medicine. Its present activities include the formulation of hospital ethical codes for Indonesian doctors and nurses, and the promotion of bioethics education at hospitals and universities through lectures, seminars, and regular meetings.
Also in 1983, the Bioethics Study Group, consisting principally of Western-trained philosophers and doctors, was established at Mahidol University, a major education and research university in Thailand, to initiate the teaching of bioethics at the university and to bring the awareness of bioethical issues to the public and concerned authorities. By 1988 three full-credit, separate courses were being taught. Through these courses students are exposed to bioethical issues and the way these issues are being addressed and resolved in the United States and other Western countries. They are also encouraged to engage in ethical reflection on those issues as they arise in Thailand, and to find solutions that reflect Thai cultural values. The group has planned to initiate a graduate program in bioethics in 1993 and has created small teams at six other medical schools to stimulate and promote bioethical activities there.
The Southeast Asian Center of Bioethics was established in the Philippines in 1987 by a group of Catholic priests and doctors as a result of the visit of the International Federation of Catholic Universities in the same year. Since its inception the Center has focused its activities on the promotion of interest in and concern with bioethics through teaching, research, seminars, and monthly meetings to discuss bioethical issues confronted by the scientific and medical community in the Philippines. Thus the value of bioethics is appreciated in Thailand, Indonesia, and the Philippines, but it is less recognized in other countries.
All the work done in bioethics has been based on Western models of health and healthcare delivery systems, and on principles derived from the Western moral tradition and specific ethical issues that are relevant to the particularities of Western culture. It is urgent that Southeast Asian academics and medical professionals begin the task of defining and clarifying bioethical issues as they affect their own countries' health and healthcare systems, and that they find resolutions in keeping with the moral principles, values, priorities, and social needs of their countries.
pinit ratanakul (1995)
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